Case 85 – summary

So, our patient has had quite a week! Thanks to your efforts, he is safely back on the ward, conscious and improving. 

Recap:

We have managed an emergency presentation of an unconscious patient with severe hypercalcaemia, hyperviscosity and an AKI.

We investigated and unconvered an underlying, previously unknown, diagnosis of IgA Myeloma. 

We involved other medical specialties and appropriately escalated his care to level 2 (HDU). 

We considered the ethical implications of treating a patient who lacks capacity to make decisions about his care. 

We touched on the legal framework of best interests decisions in the UK (Mental Capacity Act, 2005). 

We discussed specific management considerations for severe hypercalcaemia:

  • Volume expansion with intravenous 0.9% NaCl (initial rate 200-300ml/hr to maintain urine output >100ml/hr, if no oedema/overload)
  • IV bisphosphonates (caution in AKI) but remember there is a lag in their action of 2-3 days
  • s/c calcitonin in severe, refractory cases (rapid action within 24 hours but effect lost due to tachyphylaxis)

We considered the specific management of hyperviscosity syndrome:

  • Exclude other underlying CNS pathology ?acute intracranial haemorrhage
  • Assess fundi
  • Volume expansion/hydrate
  • Steroids
  • Plasma exchange
  • Treat underlying cause

Beyond initial blood tests, we discussed the pertinent investigations to consider in suspected Myeloma:

  • Imaging (see BSH guidance 2017)
  • Bone marrow biopsy including aspirate, trephine, flow and cytogenetics 

Our MDT considered a bortezomib-based chemotherapy regime appropriate in this case and initiated treatment alongside VTE prophylaxis. 

Outcome:

Our patient received 4 days of plasma exchange following his emergency admission. He commenced definitive chemotherapy for Myeloma on day 2.

After his last plasma exchange his salient bloods included:

  • Adjusted calcium 2.40
  • Paraprotein 5g/L
  • Creatinine 83

His GCS is now 15. 

He is aware of his new diagnosis and is being supported by his friends, ward staff and the specialist Myeloma nursing team. 

Thank you for your help!

Further reading:

http://www.bloodjournal.org/content/bloodjournal/119/10/2205.full.pdf 

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