Dr ahmed shabaan case

1. Case presentation
Ahmed Shaban Elshahat
Nephrology resident

2. Present History
52 years old male patient from Elmahalla
Elkobra presents with vomiting and hiccouph
1 week ago
Low pack pain
Not HTN nor diabetic

3. Medical history
NSAIDS for low pack pain last 2 weeks
Sovaldi Hx of HCV TTT 12/2016 to 26/2/2017

4. Examination
Patient appeared pale mild obese
Chest :normal bronchial breath sounds
audible S1 & S2
Abdomen : Enlarged and bloated
Bilateral mild lower limb edema

5. Investigations 23 / 8 / 2017
Hb 7.8
WBCs 12.4
PLT 150
S.Cr 5.5 (Basal cr 1 in 11/2016 rise 2.7 in 8/2017
then 3.3 )
S.K 4.1
S.Ca 13
S.Na 130
INR 1.3
Urine analysis – protn:++ pus : 50 -60
PH 7.5
H2CO3 28
Pco2 30

6. 23 / 8
24 urinary protn : 1200 mg/day
Uric acid : 15 mg/dl
PTH : 11
CRP : 30
ESR : 1st h 110
LDH : 777
S.Albumin : 3.7 mg/dl
U/S : Normal Kidneys

7. 24 / 8
Hb 9.3
WBCs 9.1
PLT 125
S.Cr 5.6
Urea 139
S.K 2 then 2.5
INR 1.2
Urine analysis pus 12-14
U.O.P 1500 /12 hour
Albumin 3.78
Protein Electrophoresis ???
Xray skull & vertebra & pelvis
Protein – Creatinine ratio 2.1
Total protein 8.4
Globin increase 4.62

8. 26 / 8
Hb 8.5
WBCs 8.8
PLT 123
S.Cr 5
Urea 123
S.K 3
S.Ca 5
PO4 5.5
Na 174
U.O.P 2400 /24 hours & Input 5500
Bence jones protein in urine -ve

9. 27 / 8
Hb 8.3
WBCs 7.5
PLT 103
S.Cr 4.6
S.K 3
S.Ca 14.7
Na 136
Albumin 3.1
U.O.P 750/ 12 hours
Biopsy was taken
PH 7.44
H2CO3 22.4
PCO2 33

10. 28 / 8
Hb 8.7
WBCs 6.4
PLT 128
S.Cr 4.7
Urea 116
S.K 3.1
S.Ca 13.9
Na 145
ALK p 99
U.O.P 1750 /24 hours
PH 7.44
H2CO3 24
PCO2 33

11. 29 / 8
Hb9
WBCs 7.4
PLT 169
S.Cr 4.8
Urea 132
S.K 2.6
Ca 9
Na 136
U.O.P 2500 / 12 hours
PH 7.5
H2CO3 27.3
PCO2 25

12. Ultrasound
LT kidney normal in site ,
size and shape with
multiple gravels
Urinary bladder : partialy full with no pathology
RT kidney multiple cysts in
upper pole 3.5 * 4 cm
two in the lower pole 1.7 *
2.1

13. X-Ray
Skull X-ray showing multiple
lucencies due to lytic lesions of
multiple myeloma

14. Management Plan
• CBC , S.Cr , Urea , S.K , Na , PO4 ,ABG , AlK P ,
U.acid
• PTH
• ESR
• Daily S.Ca , S.Albumin
• Urine analysis
• Protein electrophoresis
• Xray skull , Vertebra
• Kidney Biopsy
• Fluid chart (plenty of fluids)
• Steroids

15. Treatment
Picolax for constipation
Solurped 20 2 tabs after breakfast
500 cm Nacl solution / 6 hours
Lasix according to volume status 80 / 12 hours
Aldactone 100 mg 1 tab
Alkapress 1o mg 1 tab
2 amp K + 500 cm Nacl solution & K syrup 3*1
Cefotriaxone 1gm /24 h then Unictam 375 0ral 2*1
Biobsy : Acute tubular injury

18. Protein
Electrophoresis

19. Kidney Biopsy

20. Bone marrow
report

23. Multiple myeloma is a hematological (blood) cancer that
develops in the plasma cells found in the bone marrow.
Risk factors :
genetic factors
prevalence of MGUS
(About 19% of MGUS patients develop multiple myeloma in
about two to 19 years after MGUS diagnosis).
occupational exposure
Radiation
Age, race, and gender.

24. Symptoms
• Bone pain or bone fractures
• Fatigue
• Increased vulnerability to infections
• Increased or decreased urination
• Restlessness – eventually followed by extreme weakness and fatigue
• Confusion
• Increased thirst
• Nausea and vomiting
• Loss of appetite and weight loss
• Impaired kidney function

25. Diagnostic Criteria
The diagnostic criteria for multiple myeloma requires confirmation of one major and
one minor criteria or three minor criteria in an individual who has signs or symptoms of
multiple myeloma.
Major criteria
-Plasmacytoma (as
demonstrated on evaluation
of biopsy specimen)
-30% plasma cells in a bone
marrow sample
-Elevated levels of M protein
in the blood or urine
Minor criteria
-10% to 30% plasma cells in a bone
marrow sample.
-Minor elevations in the level of M
protein in the blood or urine.
-Osteolytic lesions (as demonstrated on
imaging studies).
-Low levels of antibodies (not produced
by the cancer cells) in the blood.

26. Classifying Multiple Myeloma
.11.Monoclonal gammopathy of undetermined significance
(MGUS)
2. Asymptomatic myeloma (further subdivided into smoldering
myeloma or indolent myeloma)
3. Symptomatic myeloma

27. Diagnostic Tests
CBC , Albumin , Ca , LDH
IgG or IgA antibodies
Serum protein electrophoresis : Monoclonal or M protein
Immunofixation electrophoresis
Freelite™ serum free light chain (FLC) assay
Urinalysis
Urine protein level
X-ray
Bone marrow biopsy/aspiration
Cytogenetic analysis(also known as karyotyping and Fluorescence In Situ
Hybridization [FISH])

28. Bone marrow aspirate
demonstrating plasma cells of
multiple myeloma. Note the blue
cytoplasm, eccentric nucleus,
and perinuclear pale zone (or
halo).

29. Treatment
Chemotherapy :
• Cyclophosphamide (Cytoxan)
• Doxorubicin (Adriamycin)
• Melphalan (Alkeran)
• Liposomal doxorubicin (Doxil)
• Panobinostat (Farydak)
Corticosteroids
Stem cell transplant

30. prognosis
Median survival is about three years,
but some patients have a life expectancy of 10 years.