Diferencia entre revisiones de «Multiple myeloma»
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==Evaluation== | ==Evaluation== | ||
*Definitive diagnosis is by biopsy of marrow or plasmacytoma | |||
*CBC | *CBC | ||
*Rouleaux formation | |||
[[File:Rouleaux.jpg|thumbnail|Roleaux formation on peripheral smear]] | |||
*BMP, ionized Ca, Mg, phos | *BMP, ionized Ca, Mg, phos | ||
**Paraproteins bind calcium, so non-ionized Ca levels could be falsely elevated | **Paraproteins bind calcium, so non-ionized Ca levels could be falsely elevated | ||
*Serum and urine testing for monoclonal protein | |||
**SPEP and UPEP electrophoresis | |||
**Bence Jones protein | |||
*Other work up contingent on presentation: | *Other work up contingent on presentation: | ||
**MRI spine: low threshold if any clinical evidence of cord compression | **MRI spine: low threshold if any clinical evidence of cord compression | ||
**Plain films of suspected pathologic fractures | **Skeletal survey: Plain films of suspected pathologic fractures | ||
**Infectious work up | **Infectious work up | ||
Revisión del 00:54 6 dic 2016
Background
- Malignant proliferation of plasma cells overproduction of abnormal antibodies (paraproteins or light-chain protein)
- Symptoms result from accumulation of plasma cells and paraproteins
Clinical Features
- Bone (plasma cell proliferation in marrow)
- Pathologic fractures
- Due to lytic lesions and osteopenia
- ”Punched-out” lytic lesion on x-ray
- Frequently involve spine, as well as ribs, skull, extremities
- Bone pain (even in absence of fracture)
- Commonly in back, ribs, extremities, often worse with movement
- Renal
- Ranges from mild creatinine elevation to ESRD
- Due to light-chain deposition, myeloma cast nephropathy and/or amyloidosis
- Hypercalcemia exacerbates
- Vulnerable to further damage from nephrotoxic mediations/contrast
- Hematologic
- Anemia
- Due to plasma cell infiltration in marrow +/- renal failure
- Hyperviscosity syndrome
- Increase serum viscosity due to paraproteins poor capillary flow and organ congestion
- Neuro
- Spinal cord compression due to vertebral fracture or collapse or plasmacytoma
- Intracranial plasmacytoma (rare)
- Peripheral neuropathy, radiculopathy
- Hypercalcemia
- due to local osteolysis
- Infection
- Impaired plasma cell function decreased effective antibody production
- Often on immunosuppressive chemotherapy or bone marrow transplant meds
- splinting due to rib pain/fractures increased pneumonia risk
Differential Diagnosis
Evaluation
- Definitive diagnosis is by biopsy of marrow or plasmacytoma
- CBC
- Rouleaux formation
- BMP, ionized Ca, Mg, phos
- Paraproteins bind calcium, so non-ionized Ca levels could be falsely elevated
- Serum and urine testing for monoclonal protein
- SPEP and UPEP electrophoresis
- Bence Jones protein
- Other work up contingent on presentation:
- MRI spine: low threshold if any clinical evidence of cord compression
- Skeletal survey: Plain films of suspected pathologic fractures
- Infectious work up
Management
- Treat pain
- Consider referring to palliative care if feasible (or suggesting consult to patient/inpatient team)
- Manage other complications:
- If febrile, get cultures, start broad-spectrum antibiotics
- Splint fractures and/or consult ortho as appropriate
- See Hypercalcemia, Hypercalcemia of malignancy
- Prednisone 60mg PO daily can be helpful in addition to standard hypercalcemia treatments
- See Cord Compression, Malignant spinal cord compression, Epidural compression syndromes
- See Renal failure
- See Anemia
- If patient is eligible for transplant and indication equivocal, may want to avoid transfusion and/or consult oncology