Case 137 – Update 4

Thanks for all your help with management of this chap. We have confirmed his diagnosis of multiple myeloma on bone marrow biopsy and completed imaging with plain films of his long bones as he has already had a whole spine MRI.

He was aggressively rehydrated and given IV bisphosphonate and his calcium improved. We started him on a pulse of steroids pending starting treatment with VTD chemotherapy and his renal function and hypercalcaemia improved significantly.

We started VTD chemotherapy and additional supportive treatment included VTE prophylaxis with LMWH which we changed to rivaroxaban when his renal function normalised, acyclovir to prevent shingles, and co-trimoxazole. We also thought about levofloxacin prophylaxis.  We asked him to get a dental review as soon as possible and started him on monthly zolendronic acid.

He responded quickly to treatment and his paraprotein was undetectable with a normal serum free light chain ratio after 4 months. His cytogenetics came back showing only a t(11;14) which was pleasing. He went on to have an autologous stem cell transplant and remained under regular review.

However, it is nearly 3 years since he completed his treatment and you notice that he has started to become a little anaemic with Hb 97, neuts 1.9 and plts 120.

What is your differential?

What actions do you take?

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