A 65-year- old male presented with low back pain and renal failure
Presented by-
Dr. Al Amin Sabuj
Phase-B resident
Department of Haematology, BSMMU
Particulars of the patient��
Name : Awal kazi
Age : 65 years
Sex : male
Religion : Islam
Marital status : married
Occupation : retired bank officer
Address : Madaripur sadar, Madaripur
Date of admission : 08.05.2022
Date of exam. : 29.05.2022
Presenting complaints
History of present illness
According to the statement of the patient, he was reasonably well 5 months back. Then he developed low back pain which is dull aching, constant, non-radiating, severity increased progressively, initially he could perform daily activities but become bedridden for last 1 month.
Pain initially relieved by taking analgesics, aggravated by movement & not aggravated at night.
There is no history of small & large joint swelling or pain, heel pain, morning stiffness or skin rash.
History of present illness (cont.)
He complains of generalized weakness associated with palpitation & lethargy.
The patient also noticed significant weight loss (not documented) over the period of his illness which is evidenced by loosening of his clothes.
He gave no history of documented fever, cough, night sweats, history of TB or contact with TB patient, headache, dizziness, visual disturbance, heat intolerance or lower urinary tract symptoms.
History of past illness�
Diabetic for 2 years, no history of taking anti-diabetic drug, but only on dietary management, not well controlled.
Hypertensive for 5 months, controlled with antihypertensive medication.
No history of a known kidney disease.
No history of any blood transfusion or major surgery.
Treatment history
With these complaints, he visited 2 local physicians and undergone several investigations.
He was referred to Dhaka for further evaluation.
He was admitted in two private hospitals in Dhaka for short duration.
Bone marrow examination was done.
Only supportive treatment were given in those hospitals.
He was advised for admission in BSMMU for better management.
He is non-alcoholic, non-smoker.
No significant family history.
He belongs to middle socioeconomic class.
History of 2 doses of COVID vaccination.
General examination
General examination (cont.)
Systemic examination
Musculoskeletal system:
No visible deformity of spinal curvature or scar mark.
Tenderness in lumbosacral region.
Restricted movement of lumbosacral spine in all direction due to pain and immobility.
SLR test is negative.
Other system examination reveals no abnormalities.
Salient features
Awal kazi, 65 years old, male, diabetic, hypertensive hailing from Madaripur got admitted with the complaints of low back pain for 5 months. The pain is dull-aching, constant, non-radiating, severity increased progressively, initially he could perform daily activities but become bedridden for last 1 month. Pain initially relieved by taking analgesics, aggravated by movement. There is no history of small joints swelling or pain, heel pain, morning stiffness or skin rash. He complains of generalized weakness associated with palpitation & lethargy.
The patient also noticed significant weight loss (not documented) over the period of his illness which is evidenced by loosening of his clothes. He gave no history of documented fever, cough, night sweat, history of TB or contact with TB patient, headache, dizziness, visual disturbance, heat intolerance or lower urinary tract symptoms. The patient is moderately anaemic, non-icteric, no oedema, clubbing, koilonychia, leuconychia, thyromegaly, lymphadenopathy. Vitals are normal. Musculoskeletal system examination reveals tenderness over lumbosacral region. Other system examination is normal.
Differential diagnosis
Hematological parameter
| 15/04/22 | 26/04/22 | 09/05/22 |
Hb (g/dL) | 11.1 | 9.9 | 8.7 |
RBC count (/L) | 3.51×1012 | 3.22×1012 | 2.73×1012 |
ESR | 110 | 42 | 50 |
MCV (fL) | 93.5 | 90.5 | 99.6 |
MCH (pg) | 31.7 | 30.7 | 31.9 |
Platelet count (/L) | 225×109 | 184×109 | 175×109 |
WBC count (/L) | 12.2×109 | 25.4×109 | 36×109 |
N/L/M/E | 32%, 64%, 2%, 2% | 32%, 64%, 3%, 1% | 30%, 67%, 2%, 1% |
Biochemical parameter
| 26.04.22 | 09.05.22 | 18.05.22 |
RBS (mmol/L) | 15.24 | 7.2 | |
S. Albumin (g/L) | | 26 | 24 |
SGPT (U/L) | 14.37 | 13 | 74 |
SGOT (U/L) | | 17 | 19 |
LDH (U/L) | | 216 | |
Calcium(mg/dL) | 13.2 | 11.3 | 10.1 |
Corrected calcium | | 12.42 | 11.38 |
S. creatinine (mg/dl) | 3.72 | 3.70 | 1.34 |
Blood urea (mg/dL) | | 91.8 | |
β2-microglobulin | ˂0.08 mg/L | | |
Peripheral blood film (09.05.22)
Dimorphic anemia with lymphocytosis
Bone marrow examination report (09.05.22):
Protein electrophoresis (18.04.22):
Urinary Bence-Jones protein:
Serum immunoglobulin electrophoresis:
Shows a broad IgG heavy chain band & also a broad lamda chain band.
Serum free light chain assay:
Kappa light chain- 89.00 mg/dl
Lamda light chain- 80.23 mg/dl
Kappa:lamda- 1.10
Bone marrow study
Protein electrophoresis
Serum immunoglobulin electrophoresis
Confirmatory diagnosis
Multiple myeloma with acute renal failure
What are the plan of further management?
1st line treatment? Why?
2nd line treatment? Why?
3rd line treatment? Why?
Thank you