A Case Report of Multiple Myeloma in a Middle-Aged Male Patient

Background

Multiple Myeloma is a neoplastic plasma cell disorder that results in proliferation, and thus overactivity, of plasma cells to produce immunoglobulin light chains, causing end-organ damage due to proteinemia. Clinical symptoms commonly manifest as renal insufficiency, with hypercalcemia and high blood creatinine, bone marrow dysfunction, such as anemia and osteolytic bone lesions or severe osteopenia, and infection due to suppression of humoral and cell-mediated immunity. While a majority of patients affected are older than 60, younger patients can also be affected; however, clinical factors such as reversibility of renal function, response to chemotherapy, molecular markers, and the need for hemodialysis show greater clinical correlation to differences in outcomes.

Case Information

This patient is a 42 y.o. male with no past medical history who presented to the ED after his PCP informed him that he had "abnormal labs.” Patient reported back and chest pain for 3 months, which he attributed to a motor vehicle accident, as well as increased fatigue and weight loss ~25 lbs in past 2.5 months. Labs were remarkable for anemia, of Cr 26 (previous baseline of 0.7 1 year ago), BUN 136, Ca 17.8, and K 6.7. CT CAP revealed multiple lytic lesions throughout and was admitted to ICU for continuous renal replacement therapy (CRRT) and evaluation of acute kidney failure in the setting of lytic bone lesions.

At this time, nephrology, hematology/oncology and palliative services were consulted for management of patients’ renal function, concerning lab findings with lytic lesions, and pain, respectively. Serum protein electrophoresis (SPEP) was ordered and indicated a kappa light chain myeloma, later confirmed by bone biopsy. He completed 5 days of plasmapheresis and was started on chemotherapy treatment for multiple myeloma, consisting of the CyBorD therapy regimen (cyclophosphamide, bortezomib, dexamethasone). Patient was transferred out of the ICU and began conventional hemodialysis (HD). At time of discharge, patient would follow with Oncology and undergo HD on an outpatient basis. Patient was also treated with Denosumab given his hypercalcemia with plan to continue as outpatient after dental clearance as well as EPO in the outpatient setting given his anemia.

Conclusions

Multiple Myeloma is a disease primarily affecting older patients, with rates peaking in the seventh decade, and as is common with multiple types of cancer, was commonly thought to have been more severe when presenting in younger patients, as a higher proportion may have cytogenetic abnormalities and physical manifestations of disease on imaging. There does not seem to be any defining presenting clinical features that may differentiate between younger and older patients presenting with signs of Myeloma. Regardless of age, certain presenting clinical factors have been associated with poor outcomes, some of the main ones being creatinine on presentation, platelet count, and serum albumin. In regards to the patient mentioned in this case, creatinine on presentation and maintenance of renal function on hemodialysis are risk factors relating to his disease prognosis, although individual patient factors and treatment options should not be overlooked.