Multiple Myeloma

Question 1

what is multiple myeloma

Answer 1

Malignant proliferation of a single clone of plasma cells (derived from b cells), producing identical immunoglobulins (IgG > IgA > IgM). The other Ig levels are low increasing susceptibility to infection

Some myeloma begin as MGUS (monoclonal gammopathies of uncertain significance) but this alone does not require treatment

Question 2

Signs and Symptoms of Multiple myeloma

Answer 2

ROAR

Renal Impairment

• light chain deposition in the distal loop of henle
• Monoclonal Ig induced changes in glomeruli = GN

Osteolytic Bone Lesions
- Myeloma cells signal increased osteoclast activation = hypercalcaemia

Anaemia, Neutropenia, Thrombocytopenia
- as a result of marrow infiltration

Recurrent bacterial infection
- due to immunoparesis and neutropenia from disease and chemotherapy treatment

Question 3

Complications of Myeloma

Answer 3

Hypercalcaemia = IV bisphosphonates
Spinal cord compression = dexamethasone
Hyperviscosity = plasmapheresis
AKI = rehydration +/- dialysis

Question 4

History of MM

Answer 4

Bone - pain that’s worse on movement, path #s
Hypercalcemia - abdo pain, vomiting, polyuria, depression, weight loss, fatigue, weakness
Renal - colic from stones, nephrotic
Anaemia - SOB, pale, tired
Bleeding - bruising, GI bleeding
Hyperviscosity - headache, visual changes
bacterial infection - UTI and Pneumonia
Skin - pruritis, purpura

Question 5

Examination

Answer 5

Weight loss, pallor, bruising
Lymphadenopathy and splenomegaly are rare
Signs of chest infection 
Signs of spinal cord compression
Bony tenderness and deformity (kyphosis)

Question 6

Ix and Diagnosis

Answer 6

Bloods:
CBC (anaemia, high ESR)
UEC (high urea, Cr and Ca)
Serum eletrophoresis for serum free light chains and immunoglobulins

Urine:
Urine electrophoresis

imaging:
Skeletal survey
CT or MRI

Bone marrow:
Trephine or aspirate - look for B2 microglobulins

DIAGNOSIS:

1. monoclonal protein band on s or u electrophoresis
2. Increased plasma cells on B marrow biopsy
3. End organ damage - hypercal, renal insuf, anaema, #

Question 7

Management:

Answer 7

Supportive:

• Analgesia for bone pain (AVOID NSAIDs)
• Bisphosphonates to reduce # risk + local radiotherapy
• Transfusion and EPO for anaemia
• Hydration + bicarbonate for renal disease
• Broad spec Abx for infection
• Regular IV Ig infusions

Chemotherapy
- Intensive if young with minimal comorbidities

Stem cell transplant in young patients

Question 8

Outcomes

Answer 8

3-4 year survival, death commonly due to infection or renal failure