Case Studies
Case 6.7 Multiple myeloma
A 66-year-old man presented with sharp, constant, low back pain, dating from a fall from a ladder 6 weeks earlier. On direct questioning, he did admit to vague malaise for over 6 months. On examination, he was in considerable pain but otherwise seemed fairly fit. He was mildly anaemic but had no lymphadenopathy and no fever. There were no signs of bruising, no finger clubbing, no hepatosplenomegaly and no abdominal masses. On investigation, his haemoglobin was low (102g/l) due to fewer red cells but his white-cell count was normal (6.2 x 109/l). He had a normal differential white-cell count and a normal platelet count but his ESR was 98mm/h. Total serum proteins were raised at 98g/l (NR 65-75g/l) and this resulted on the rouleaux seen on the blood film (agglutinated red cells). His serum albumin, creatinine and urea were normal. He had a raised serum calcium level (3.2mmol/l) but a normal alkaline phosphatase. Serum protein electrophoresis revealed a monoclonal band in the gamma region, with considerable immunosuppression of the rest of this region. The band was typed by immunoelectrophoresis and shown to be IgG of kappa type (Fig. C6.1). Quantitation of serum immunoglobulins showed a raised IgG of 67g/l (NR 7.2-19.0g/l), a low IgA of 0.3g/l (NR 0.8-5.0g/l), and a low IgM of 0.2g/l (NR 0.5-2.0g/l). Electrophoretic examination of concentrated urine showed a monoclonal band in the beta region. On immunoelectrophoresis, this band was composed of free kappa light chains. X-rays of his back showed a small, punched-out lesion in the second lumbar vertebra and destruction of the symphisis pubis but a subsequent skeletal survey did not show any other bone lesions.
Bone marrow examination showed an increased number of atypical plasma cells; these constituted 45% of the nucleated cells found on the film. This man showed the features required for a diagnosis of multiple myeloma (see Table 6.5).
|
