PGY2 Courtney Hanlon presented a case of a 73 y/o M with history of aortic stenosis (s/p mechanical AVR, on warfarin), chronic Aflutter/Afib, HTN, CKD, BPH and sciatica presents with decreased urinary output, decrease frequency, mild dysuria and increased peripheral edema over the last few weeks. The patient has been taking his medications as prescribed and denies taking NSAIDs. Reports recent history of nausea and NBNB emesis with decreased PO intake. Denies recent illness, fever, SOB, chest pain, orthopnea, cough, PND or abdominal pain.
Regarding his back pain, the patient states he has had 3 weeks of worsening L sided sciatic-type pain, worse with movement, described as shooting pain down posterior leg, consistent with prior flares. He has to lie flat because of this back pain/sciatica. Denies recent trauma, falls, saddle anesthesia, paralysis and steroid use. Home medications include amlodipine, warfarin, furosemide, hydralazine, diltiazem and tamsulosin. Social history pertinent for being currently incarcerated, denies any tobacco/ethanol/drug use.
Vital signs: T 36.8C, HR 94, RR 17, BP 160/64, SpO2 100%
Physical Exam significant for appearing uncomfortable, irregular HR with mechanical AV click, +crackles at RLL, abdomen diffusely tender, normal neuro exam and 2+ pitting edema to upper shin.
CBC: WBC 15.2 > Hb 10.6/Hct 30.7 <Plt 354
Diff: 47.2% PMN, 45.9% lymph, 6.2% monocytes, 0.1% eosinophils, 0.6% basophils
Na 138/K 5.2/Cl 101/HCO3 20/BUN 65/Cr 6.07 <Glucose 99 (baseline Cr 1.5-1.7)
ALP 57>T.protein 5.7/Albumin 3.9/AST 31/ALT 24/Tbili 0.5/Dbili 0.2
Coags: PT 43.5, INR 4.63, PTT 73.3
CXR with small right pleural effusion. No evidence of pulmonary edema or focal consolidation.
Cardiac workup with elevated troponin and BNP. TTE normal with functioning prosthesis of aortic valve.
Infectious workup was negative.
Heme workup revealed peripheral smears for mature lymphocytes and small number of plasma cells/plasmacytoid lymphocytes. SPEP/UPEP showed two free kappa light chain bands identified by immunofixation in gamma region. K/L ratio was elevated 465.38.
Renal workup was significant for UA with 100 proteins but elevated urine protein/cr at 2.28.
CT A/P: Diffuse heterogeneity of the osseous structures with multiple lytic lesions, and there is a large lytic soft tissue lesion within the L5 vertebral body extending posteriorly and causing narrowing of the spinal canal. Nodular liver contour and small ascites.
Bone marrow biopsy showed normocellular (50%) bone marrow with extensive involvement by kappa light chain plasma cell myeloma and chronic lymphocytic leukemia.
Treatment: Heme consulted and recommended immediate transfer to Heme wards for emergent chemo initiation due to concern for TLS. He was started on CyBorD.
Take home points:
- A low globulin gap is just as important as a high globulin gap. Normal range of globulin gap is between 2.5-4. Causes of low globulin gap: congenital vs combined immunodeficiency state vs acquired (Multiple Myeloma, AL amyloidosis, CLL, Lymphoma, Nephrotic syndrome).
- A low globulin gap also warrants a workup that may include SPEP, UPEP and serum free light chains.
- With concern of multiple myeloma, the workup includes: SPEP, UPEP, serum free light chains, Quantitative Ig, skeletal survey, bone marrow biopsy, PET CT to evaluate for solitary vs systemic disease, imaging to evaluate for cord compression if concerned.