4th Edition

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.

  • 1. What does the X-ray show?

    Correct answer:
    Plain X-ray showed multiple lytic lesions in her left humerus.

  • 2. What is the differential diagnosis?

    Correct answer:
    Metastatic cancer

She is referred to an orthopaedic surgeon who requests a myeloma screen.

  • 3. What is a myeloma screen?

    Correct answer:
    The diagnosis requires three tests:
    Serum paraprotein levels (serum electrophoresis and immunofixation) and serum free light chain assays or urinary Bence Jones proteins.
    Skeletal survey (to detect lytic bone lesions)
    Bone marrow aspirate and trephine to detect clonal plasma cells.

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
  • Increased serum calcium
  • Lytic bone lesions
  • Anaemia
  • Renal failure

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.

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