Chapter 31: The pensioner who found washing up painful
An 80-year-old pensioner complained to her GP that her left upper arm hurt when she did the washing up. After her third visit over a month, he sent her to hospital for an X-ray of her left humerus.
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1. What does the X-ray show?
Correct answer:
Plain X-ray showed multiple lytic lesions in her left humerus.
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2. What is the differential diagnosis?
She is referred to an orthopaedic surgeon who requests a myeloma screen.
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3. What is a myeloma screen?
Bone marrow aspirate and trephine to detect clonal plasma cells.
| Multiple myeloma (all three criteria must be met) | Presence of a serum or urinary monoclonal protein | Presence of clonal plasma cells in the bone marrow or a plasmacytoma | Presence of end organ damage felt to be related to the plasma cell dyscrasia
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Her serum electrophoresis showed an IgG kappa monoclonal paraprotein that was quantified as 30g/dL.
Her bone marrow examination showed a heavy >90% infiltrate of plasma cells that are identified by CD138 immunostain.
She was treated with non-steroidal anti-inflammatories to palliate her symptoms, zoledronate to reduce the risk of fractures and cyclophosphamide, thalidomide and dexamethasone (CTD) chemotherapy. She received a grant from Macmillan to buy a dishwasher.