A 60YearOld Woman With Fever, Cough and Low Back Pain Chapter 8

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A 60-Year-Old Woman With Fever, Cough and Low
Back Pain Chapter 8
Eugene G. Martin, Ph.D. Associate Professor of
Pathology Laboratory Medicine

• Based upon LABORATORY MEDICINE CASEBOOK. An
  introduction to clinical reasoning
• Jana Raskova, MD Professor of Pathology
  Laboratory MedicineStephen Shea, MD
  Professor of Pathology Laboratory
  MedicineFrederick Skvara, MD Associate
  Professor of Pathology Laboratory MedicineNagy
  Mikhail, MD Assistant Professor of Pathology
  Laboratory MedicineUMDNJ-Robert Wood Johnson
  Medical SchoolPiscataway, NJ

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History and Presentation

• A 60 y.o. ? presented with fever and a productive
  cough of approximately two months duration.
• Chief complaints Fatigue and low back pain
• Physical Exam
• Alert ?, oriented
• BP 120/90
• HR 90 bpm RR 23
• Temp. 102.2 oF
• Exam of lungs bilateral rales
• Rest of exam - unremarkable
• Sputum was obtained for Gram stain and culture
• A chest X-ray was obtained

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Constructing a differential

• What entities are you considering from the
  history and her general physical appearance?
• Generate a broad list based on the possible
  diagnoses for each major symptom complex and
  major physical findings, and then narrow this
  down by looking at the overlapping disease
  processes

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Construct a Differential

• Possibilities that might account for this
  scenario of fever, fatigue, bilateral rales and
  low backpain

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Radiology
Normal Flat Plate
Patient On Admission
Bilateral infiltrates
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HEMATOLOGY
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Is this a Shift to the Left?

• Includes
• Unilobed and two lobed nucleus predominate
• Seen in
• Acute infection
• Metaboloc acidosis
• Necrosis myocardial infarct. malignant tumors
• Blood disease
• hemolytic crises,
• severe blood loss
• chronic  granulocytic leukemia,

Band cell
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CHEMISTRY
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Electrolytes
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Treatment

• Patient was diagnosed with ? placed on a two week
  course of antibiotics and was advised to schedule
  a follow-up visit after two weeks

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HEMATOLOGY 2 weeks later
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CHEMISTRY 2 Weeks later
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Urinalysis
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Peripheral Blood Smear
Patient
Normal
Normochromic,normocytic anemia
Rouleaux
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Culture results

• Gram positive cocci in pairs and chains
• Consistent with Streptococcus pneumoniae

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Skull x-rays

• Randomly distributed, rounded, punched out lytic
  lesions throughout the skull. Multiple myeloma
  could also resemble metastatic breast carcinoma.
  Treated breast carcinoma, however, often appears
  sclerotic rather than lytic.

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Serum Protein Electrophoresis

• Note sharp peak in the gamma region indicative of
  a monoclonal protein

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Serum Immunoelectrophoresis
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Bone Biopsy

• Bone biopsy representing more than 90 percent
  replacement of normal marrow with plasma cells.
• Definitive diagnosis requires gt 10 to 15 percent
  plasma cell involvement of the bone marrow.
• http//www.aafp.org/afp/990401ap/1885.html

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Summary of Findings

• Lab Findings
• Normocytic, normochromic anemia
• Rouleaux formation on peripheral blood smear
• Hypercalcemia
• ? Ca, ? alk. Phos.
• Abnormal renal function
• X-ray
• Skull and rib Punched out lesions compatible
  with bone resorption
• Special studies
• Immunoelectrophoresis IgM immunoglobulin
• Bence Jone proteinuria
• Bone Marrow biopsy Plasma cell infiltrate

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Presenting Signs Symptoms

• Clinical features result from
• Multiple bone tumors ?Tissue damage
• Complications from monoclonal component
• ? infections due to depressed immunoglobulin
  levels
• Skeletal system
• Most common symptom - bone pain from fractures
• Compression fractures of thoracic and lumbar
  vertebrae usually causes severe spasms and back
  pains
• Clavicular and rib fractures ?Pleuritic pain
• Hypercalcemia
• ? Nausea, confusion, polyuria and constipation
• Anemia
• Easy fatigability or dyspnea on exertion
• Infection
• Recurrent bacterial infections are a major cause
  of illness and most common cause of death
• Amyloid
• Systemic amyloidosis with myltiple myeloma could
  present with weakness, weight loss, ankle edema,
  dypsnea, paraesthesias, lightheadness or syncope
• Cardiac exam could reveal ventricular gallop as a
  sign of failure secondary to severe anemia,
  hypercalcemia, or amyloaid heart disease

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Disease Spectrum

• Bone Destruction
• 20 of patients with MM have only bone
  demineralization
• Skeletal radiographs including both femurs will
  support MM in 70 of patients
• 10 will have a normal skeletal survey because at
  least 30 of bone Ca must be lost before
  radiographic changes are evident
• Multiple Myeloma is the MOST COMMON primary
  cancer of bones in adults
• Renal Failure
• Occurs in 25 of patients
• Most patients have no symptoms (mild azotemia),
  but fatigability, nausea, vomiting and confusion
  occurs with severe renal failure Bence Jones
  protein occurs 90 of time w/ or w/out
  hypercalcemia
• Infection
• Most frequent cause of death most common
  Strep. Pneum, H. influenzae
• Hypercalcemia
• At diagnosis, ¼ of patient have serum Ca gt11.5
  mg/dl. Nausea, confusion, polyuria and
  constipation are common.

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Lab Procedures

• CBC
• Anemia is a major diagnostic clue
• Several factors bone marrow infiltration by
  plasma cells, renal failure and chronic disease
• Hct. May be 6 points less than expected because
  high levels of IgA or IgG frequently increase the
  plasma volume
• Chemistry
• Hypercalcemia, hyperuricemia, increase serum
  creatinine 2o to muliple myeloma or renal failure
• LDH is noted in 10-15 of patients usually
  signifies a poor prognosis
• Serum Alk. Phos. Is usually normal, but may be
  elevated in patients with healing pathologic
  fractures
• Proteinuria occurs in 65 of patients
• Radiology
• Chest X-ray may reveal widespread osteolytic
  lesions
• Cardiomegaly in patients with cardiac amyloidosis
• Urinalysis
• Proteinuria 65 of patients
• Recognition of light chain protein (Bence-Jones
  protein) depends on demonstration of monoclonal
  light chain by immunoelectrophoresis

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Therapy for Multiple Myeloma

• A disease in which a cure is a rarity
• Limitations of effective therapy are primarily
  related to low cell proliferation rate and
  multi-drug resistance
• Most patients succumb to disease within 36-48
  months
• Supportive care Growth factor support with EPO
  replacement, GM-CSF for stimulating the WBC to
  decrease or prevent neutropenia

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Case Summary

• Final Diagnosis
• Bilateral Bronchopneumonia
• Multiple Myeloma

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References

• http//www.clevelandclinic.org/myeloma/DiagnosisAn
  dTreatmentOfMultipleMyeloma.html
• http//www.aafp.org/afp/990401ap/1885.html

• Websites containing information on Multiple
  Myeloma