The family opted to withhold further invasive procedures, including bone marrow biopsy. Owing to the advanced stage of disease at presentation, the prognosis was poor. The patient was started on chemotherapy and a 1.0 volume plasma exchange was initiated to alleviate signs and symptoms consistent with hyperviscosity. Note the intense band in the gamma region and the corresponding M-spike on densitometry.Ī diagnosis of multiple myeloma with hyperviscosity syndrome was reached on the basis of the presence of IgA M-protein, hypercalcemia, renal insufficiency, anemia, multiple lytic bone lesions, and increased serum viscosity. Agarose gel scan and densitometry tracing for serum protein electrophoresis. Rouleaux formation causes decreased flow of blood in the vessels. Peripheral blood smear demonstrated rouleaux formation, which is the stacking of red blood cells that may occur when there is increased protein concentration in blood, especially fibrinogen and globulins. The noted hyperviscosity could also explain the patient's symptoms of altered mental status, slurred speech, and gait instability ( 5). Other test results included β 2-microglobulin 18.5 mg/L, PTHrP, 3.3 pmol/L (RI, 0.0–2.3 pmol/L), and serum viscosity 4.4 (RI, 1.6–2.0). Immunoglobulin measurements revealed the following: IgG, 317 mg/dL IgA, 8120 mg/dL and IgM, 15 mg/dL.
ALTERED MENTAL STATUS FREE
Quantitative serum κ free light chain (FLC) was increased, 145 mg/dL, with κ:λ FLC ratio being 166.60 (RI, 0.26–1.65). Immunofixation electrophoresis identified the M-spike as IgA κ. 1) and urine protein electrophoresis demonstrated M-spike in the γ regions. The findings of hypercalcemia, renal dysfunction, anemia, and lytic bone lesions are classic manifestations of multiple myeloma ( 4). The survey demonstrated multiple lytic lesions in the skull, pelvis, femurs, left humerus, and left scapula. Our patient's constellation of signs and symptoms, coupled with initial laboratory results, prompted concern for an underlying malignancy, leading to a workup that included a skeletal survey. What are the differential diagnoses in this patient? What are the signs/symptoms of hypercalcemia? In a recent study by Szymanski et al., PTHrP production accounted for only 38% of MAHC cases, followed by osteolytic bone lesions at 27.3% ( 3). Historically, parathyroid hormone-related peptide (PTHrP) 2 production has been reported to be responsible for up to 80% of malignancy-associated hypercalcemia (MAHC). Other causes of hypercalcemia include sarcoidosis, vitamin D toxicity, milk-alkali syndrome, familial hypocalciuric hypercalcemia, and side effect of drugs like lithium and thiazides. Primary hyperparathyroidism and malignancy make up the vast majority of hypercalcemia cases ( 2). Patients with severe hypercalcemia may develop confusion, altered mental status, and gait instability ( 1). Common manifestations of hypercalcemia include nausea, vomiting, abdominal pain, polydipsia, polyuria, and lethargy. This variability is dependent upon the rate and magnitude of calcium increase. There is considerable variability in how patients with hypercalcemia present. Extensive workup for the primary cause of hypercalcemia ensued. He was transfused with 2 units of packed red cells for symptomatic anemia. The patient was managed with intravenous normal saline, calcitonin, and pamidronate for hypercalcemia. Brain CT (computed tomography) scan ruled out a cerebrovascular accident, intracranial hemorrhage, or mass lesion in the brain. Initial laboratory results are shown in Table 1. He had no history of hematochezia or melena. He had a previous history of smoking (34 pack-years). According to his medical records, a colonoscopy performed 8 years earlier was unremarkable.
His medical history was significant for hypertension, hyperlipidemia, and benign prostatic hyperplasia. Other vital signs include blood pressure, 149/80 mmHg temperature, 36.1 ☌ (97 ☏) and respiratory rate, 16 breaths per minute. Physical examination was remarkable for generalized weakness, pallor, and tachycardia with a heart rate of 102 beats per minute. His family reported a 14-pound weight loss over the past 3 months, along with decreased energy, shortness of breath on exertion, and fatigue.
A 72-year-old man presented to the emergency department with a 3-day history of slurred speech, altered mental status, and unstable gait.
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