Case study - Diagnosing multiple myeloma

11 October 2013

A case of self-diagnosed arthritis was found to be myeloma. Dr Harry Brown investigated this myeloma patient in primary care.

The patient thought her joint pains might be arthritis, but a detailed history and further tests indicated otherwise

A 67-year-old retired schoolteacher, who was an infrequent attender, visited the GP because she had been troubled by 'arthritis' for the past few months. Her knees and shoulders were particularly affected.

She brought a newspaper cutting which listed a number of supplements and therapeutic agents that could be of benefit in arthritis, and wanted my opinion about them.

None of them was a particularly conventional treatment and I asked if she minded if I could start from the beginning and take a history. Apart from the 'arthritis', which she defined as aches and pains in the muscles and joints, she also felt tired all the time.

On direct questioning, she revealed that she was very stiff in the morning and it could take a couple of hours for her to get going. She had no headaches or visual disturbance and no family history of arthritis. She was on no regular medication.

Physical examination was unremarkable, and her shoulders and knees were normal. Her BP was normal and she had neither muscle tenderness nor tenderness in her temporal arteries.

Blood tests and X-rays

I asked if we could put aside the newspaper article for the meantime and do some blood tests, as well as an X-ray of her shoulders and knees.

Within a few days her results filtered through and my attention focused on her raised plasma viscosity of 2.04. I saw her again and worked on the possibility that she might have polymyalgia rheumatica.

I went back to clarifying the history; she had no headaches or visual symptoms. Her X-rays were normal, her alkaline phosphatase was mildly elevated and she had a borderline anaemia.

I started her on a suitable dose of oral steroids, prescribed bone and gastric protection, and arranged to see her the following week.

I was somewhat surprised during that consultation, when she told me she had noticed some improvement in her symptoms, but this fell rather short of the dramatic improvement I had expected if my original diagnosis were to be confirmed.

I decided to keep her on the same dose of steroids, but started to think about other diagnoses and sent off a battery of tests.

The following week, her plasma protein electrophoresis came back abnormal, suggesting a myeloma. I referred the patient urgently to the haematologists and stopped her steroids.

The diagnosis of multiple myeloma was sustained after further investigations and the patient still attends the outpatient clinic for regular follow-up. She currently remains reasonably well.

Multiple myeloma is a malignancy of plasma cells, which produces a monoclonal (all the same) immunoglobulin. It mainly affects the over-60s age group. It may present with fatigue or bone pathology, such as bone pain, or even pathological fractures. It is important to note that multiple myeloma can be diagnosed in an asymptomatic phase.

Increased osteoclast activity can result in hypercalcaemia, which can lead to, among other symptoms, weakness, polyuria, constipation and confusion. Marrow involvement can result in anaemia and infections.

Abnormalities

Emergency presentations include hyperviscosity, hypercalcaemia, acute renal failure and cord compression. Plasma viscosity or ESR may be raised and there may or may not be abnormalities in the initial FBC.

A serum protein electrophoresis, along with a request for Bence Jones protein in the urine, could suggest the diagnosis.

If abnormal, this should trigger an urgent referral to haematology for a further diagnostic work-up, which usually includes a skeletal survey and bone marrow examination.

Although myeloma is considered incurable, symptomatic patients generally receive outpatient chemotherapy and fit patients may be considered for bone marrow transplant.

With treatment, patients can survive for three to five years from diagnosis and sometimes even longer; the outlook can be variable.

Treatment can include therapy for anaemia, infection and hypercalcaemia. Pathological fractures may require orthopaedic input and radiotherapy may have a role in the management of bone pain.

Bisphosphonates can help to improve skeletal morbidity and analgesics can help ease bone pain. Towards the end of the illness, palliative care may need to be considered.