Hypercalcemia due to Multiple Myeloma

Author: V. Dimov, M.D., Assistant Professor, University of Chicago
Reviewer: S. Randhawa, M.D.

A 60-year-old female presented to the ER complaining of back pain, weakness and decreased appetite for one week.

Past medical history (PMH)

Diverticulitis.

Medications

No outpatient medications.

Physical examination

VSS.
Limited movement in the lumbar spine.
No focal neurological changes.

Laboratory results

Hemoglobin 7.7 mg/dL
Hematocrit 23
Platelets of 106/mm3
BUN of 35 mg/dL
Creatinine of 2.7 mg/dL
Ca of 16.6, the repeated Ca is still 16.2.


CBC and CMP (click to enlarge the images).


Hypercalcemia (click to enlarge the images).


Urinanalysis (click to enlarge the images).

What is the most likely diagnosis?

Anemia.
Thrombocytopenia.
Renal insufficiency.
Hypercalcemia.

There is no previous baseline of laboratory results, so we cannot really say if the changes are new or chronic.

What happened?

The patient is admitted for anemia, renal insufficiency, and hypercalcemia.

What would you do next?

Correct hypercalcemia with:
NS IVI
Lasix (furosemide)
Pamidronate infusion
Calcitonin

Check:
CMP
Repeat H/H
Lumbar spine X-rays

Type and screen 2U PRBC
Transfuse 2 U PRBC if Hgb is less than 8

Work-up of anemia:
Iron profile and ferritin
B12, folate
Reticulocyte count
Peripheral smear review
Stool guaiac x 2

Protein is 13.5 mg/dL, albumin is 3.6 mg/dL.

Periphreal smear review: Normocytic anemia without polychromasia. Thrombocytopenia. Rouleax. Rule out plasma cell dyscrasia.

What is the likely diagnosis?

Multiple myeloma.

Beta 2 microglobulin is 10.6.

Immunoelectrophoresis is shown below:


Serum immunoelectrophoresis (click to enlarge the images).

What happened next?

With treatment, calcium decreased to 12.4.

A hematology consult was called. Bone marrow biopsy will be done.

Survey radiographs of the skull, spine, ribs, pelvis and upper and lower extremities (large bones):

X-ray of skull, CXR, spine (click to enlarge the images).


Pelvis X-ray, femur and fibula (click to enlarge the images).

Multiple bony structures demonstrate changes of multiple myeloma or diffuse metastatic neoplasm.

The lateral view of the calvarium demonstrates multiple focal radiolucencies. Radiographic findings would be consistent with diffuse involvement with multiple myeloma. Spinal segments demonstrate mild diffuse osteopenia. Radiographs of the upper extremity bones demonstrate radiolucencies associated with the proximal humeri bilaterally. The ribs demonstrate diffuse osteopenia with coarsening of the trabecular pattern suggesting a bone marrow replacement process. There is a pathological fracture at the lateral aspect of the left seventh rib. The AP radiograph of the pelvis demonstrates diffuse osteopenia with several focal radiolucencies involving the inferior aspects of the ilia and the inferior pubic rami and ischia bilaterally. Focal radiolucencies involving the proximal femora bilaterally suggesting a bone marrow replacement process. There is a small focal radiolucency involving the proximal right fibula which could represent early bony destructive change.

CT scans of chest, abdomen and pelvis did not show masses suggestive of malignancy. The scans did show diffuse skeletal lytic lesions which may represent multiple myeloma or other metastatic disease.

Final diagnosis

Multiple myeloma pending the bone marrow biopsy result.

Related resources


Multiple Myeloma - Mayo Clinic video: May 12, 2010 — In the following video, Rafael Fonseca, M.D., Director of the Cancer Center at Mayo Clinic in Arizona, provides an overview of the condition Multiple Myeloma (a cancer that arises from the blood marrow) and describes treatment options.

Related reading

Multiple Myeloma. NEJM review, 2011.

Published: 06/12/2006
Updated: 03/12/2011

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