Clinical features and diagnosis of multiple myeloma

Abstract

EM, an 85 year-old female, was admitted to the Medical Teaching Unit with a one-week history of confusion. In the Emergency Department, she was disoriented and later became somnolent. During the month prior to admission, she had experienced progressive mid-back pain, and had been diagnosed with a T8 compression fracture. Laboratory investigations showed a hemoglobin of 81 g/L with mean corpuscular volume of 101 fL. Rouleaux formations were seen on peripheral smear. EM had elevated creatinine (133 mmol/L), urea (11.2 mmol/L), and ionized calcium (1.97 mmol/L); however, parathyroid hormone levels were normal, as were iron studies, vitamin B12, folate, and thyroid stimulating hormone (TSH). Urine culture revealed Escherichia coli bacteriuria, which was treated with ceftriaxone. Pamidronate was administered for hypercalcemia. Early into the admission, she became fluid overloaded and required diuresis, while simultaneously receiving intravenous fluids for her hypercalcemia. Multiple myeloma was considered as the cause of EM’s constellation of symptoms, so a serum protein electrophoresis was performed, revealing an IgA monoclonal protein spike. Free light chain analysis showed an increase in free kappa light chains (7.69 mg/L) with a markedly elevated kappa/lambda ratio of 157.5.