Case based Discussion
A 75 year old woman with a productive cough falls in a nursing home. Whilst being treated in the Care of the Elderly ward she reports pain in her left elbow
Examiner: Please describe this X-ray
Candidate:AP plain radiograph of the left elbow with no fracture seen. There are multiple irregular lytic lesions with a “punched out” appearance and no periosteal reaction
Examiner: What is your diagnosis and differentials?
Candiate:Multiple myeloma. Differentials include osteomyelitis and metastatic disease. The productive cough could be due to a lack of normal immunoglobulin production (due to myeloma) making her more susceptible to bacterial infection.
Examiner: You review her recent blood tests. There is a FBC and U&E on the system. What derangements could be caused by myeloma? What further blood tests would you like?
Candidate:FBC: normocytic, normochromic anaemia
U&E: renal failure
Also useful would be Bone Profile for hypercalcaemia. ESR is commonly raised.
Examiner: What are the treatment options and prognosis for multiple myeloma?
Candidate:There is no cure for multiple myeloma, but treatment can improve survival. Radiotherapy can trigger re-ossification of lesions and significantly improve bone pain. Chemotherapy affects normal bone marrow stem cells, and therefore can cause further reduction in normal blood constituents. It is sometimes used on its own palliatively. Chemotherapy can also be given in conjunction with stem cell therapy. High dose chemotherapy agents are given, killing both the myeloma cells, and the healthy stem cells. The stem cells are then replaced with either donated or the patient’s own previously harvested stem cells.Bisphosphinates can be used to reduce hypercalcaemia. Surgery is indicated prophylactically or to stabilise pathological fractures. Spinal deposits/fracture may warrant decompression and/or stabilisation..With treatment survival can improve significantly, from 6-12 months to 3-5 years. Prognosis of solitary lesions is better than multiple lesions.