Medical symptom checker- Back pain cause - Multiple myeloma
It is a blood cancer or hematological malignancy. It is due to proliferation of plasma cells that leads to production of monoclonal immunoglobulin ( IgA and IgG) that belong to the group paraprotein. The plasma cell may result in bone lesions.
The aetiology is unknown. It is suggested that it is cause by viral trigger. Abberations of chromosome will leads to production of interleukin - 6 ( IL- 6 ) which is a potent growth factor cytokines that cause proliferation of the plasma cell.
Multiple myeloma is associated with occupational exposure such as benzene exposure, agricultural works or ionizing radiation. It is common in afro- caribbean compare to caucasian or asian. The peak age is 70 years old and the incidence is around 4 per 100 000/year .
Multiple myeloma is diagnosed incidentally during routine blood test. Patient may complains of sudden and severe pain in the back or ribs that are caused by vertebral collapse or pathological fracture. ( Bone pain that is often on the on the back or ribs. ) Patient also complains of recurrent infection . Generally. they may suffer from symptoms of hypercalcaemia such as nausea, tiredness, lethargy, constipation, polyuria and mental changes. Increase in blood viscosity ( blood hyperviscosity ) may happen and lead to visual disturbance, bleeding and headache.
On examination, patient looks pale ( pallor ) , increase heart rates ( tachycardia ) , dehydrates ( signs of dehydration ), develop signs of heart failure and flow murmur can be detected. Patient may also suffer from carpal tunnel syndrome, hepatosplenomegaly, peripheral neuropathies and purpura.
Pathologically, excess production of protein known as osteoprotegerin ligand will leads to tumor expansion and activation of osteoclast which cause lytic lesion/bone lesion. Impairment of humoral activity as well as opsonization will lead to recurrent infection especially by the encapsulated bacteria.Impairment of coagulation factor and platelet function may increase bleeding tendency. In late stage, thrombocytopenia may occurs.
Multiple myeloma can be stage by Durie/Salmon staging that is based on calcium level, serum haemoglobin level, creatinine level, immunoglobulin level and number of bone lesions detected radiographically on the skeletal survey.
The investigation includes blood test, blood film, bone marrow aspirates and trephine, serum urine electrophoresis and chest, pelvis or vertebral x- ray and MRI.
Blood test consists of full blood count that show nomochromic nomocytic anaemia. ESR and CRP tests that show elevation of ESR and CRP. ( CRP may be normal in some cases where ESR is elevated ).Urea and electrolytes show elevation of calcium and creatinine in 45 % of cases. Alkaline phosphate is typically normal.
Blood film shows a rouleaux formation and bluish background. Bone marrow aspirates and trephine will shows an increase in plasma cell.The plasma cell is identified as larger cell with blue cytoplasm , perinuclear halo and eccentric nuclei. Present in more than 20 % of cases.
Serum and urine electrophoresis show the present of Bence - Jones protein in 70% of cases that consists of free light chain , kappa and gamma. and serum paraprotein that consists of 2/3rd IgG and 1/3rd IgA.
Chest, pelvic or vertebral x- ray will show pathological fracture or osteolytic lesions without sclerosis surrounding the region. MRI scan is useful to identify any cord compression.
Management include emergency . medical and supportive managements.Emergency treatment include rehydration. Follow by plasmapheresis and dialysis.Any cord compression or bone pain should be treated with radiotherapy. Any pathological fracture is treated normally.
Medical treatment include chemotherapy that consists of VAD regimen ( vincristine, adriamycin and dexamethasone.) or prednisolone and melphalan regimens with 60% respond. Interferon - alpha should be added as it will prolong the plateau or remission phase achieved from chemotherapy. In selected patient, stem cells or bone marrow transplants and high dose of chemotherapy can be an option.
Supportive treatment includes antibiotic, allopurinol ( to protect against gout and hyperuricaemia) , erythropoietin, hydration, bisphosphanates and blood products.
The complication of multiple myeloma includes carpal tunnel syndrome, spinal cord compression, pathological fracture, polyneuropathies, and renal failure in 1/3 rd of patient.
The duration of survival from multiple myeloma is 4- 6 years after diagnosis. The prognostic indicator includes age, plasma cells labeling index, creatinine and beta microglobulin. Poor prognostic factor is if the patient is monosomy of chromosome 13.
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