Multiple Myeloma (MM)

Move the patient like their bones are broken - Lytic lesions produce compression fractures, vertebral collapse, loss of height and kyphosis. Transfer and position with the awake patient guiding you where possible, pad every prominence, and log-roll rather than lift under the arms.

Cord compression is an emergency, not a finding - Spinal cord compression from vertebral fracture or plasmacytoma is managed aggressively with neurosurgery or orthopedics and radiation. Ask about back pain, radicular pain, weakness and bowel or bladder change, and record a motor and sensory level before neuraxial anesthesia or prone positioning.

Protect the kidney deliberately - Most MM patients have some renal injury. Avoid NSAIDs, renin-angiotensin inhibitors, IV contrast and hypotension, all of which are documented precipitants. Keep the patient adequately hydrated, and avoid loop diuretics - they precipitate cast formation. Dose renally cleared drugs to the measured creatinine and check whether the patient is on dialysis.

Hypercalcemia - Bone demineralization drives thirst, polyuria, abdominal pain, nausea, vomiting and altered mental status, and the polyuria leaves patients dry before you ever see them. Check a calcium and a metabolic panel; treatment is isotonic saline volume expansion plus calcitonin and/or bisphosphonates.

Cytopenias and platelet dysfunction - Get a CBC with platelets and a type and screen. Marrow replacement causes anemia, thrombocytopenia and leukopenia, and the paraprotein itself impairs platelet function, so the count can look adequate while the bleeding is not.

Hyperviscosity is a stop sign - Bleeding, confusion, neurologic symptoms, vision changes and heart failure in a myeloma patient means hyperviscosity, which is a medical emergency treated with plasmapheresis. Postpone the elective case and get the patient plasmapheresed.

Look in the airway before you commit - Extramedullary plasmacytoma is 80% to 90% head and neck and aerodigestive - oral cavity, tonsillar fossa, nasal cavity and paranasal sinuses - and laryngeal involvement causes hoarseness, dysphonia, dyspnea, wheezing and airway obstruction. Ask about voice change, nasal obstruction and dysphagia, examine the oropharynx, and have a video laryngoscope up.

Neuropathy and amyloid - Peripheral neuropathy or carpal tunnel in a myeloma patient should raise underlying amyloidosis, which brings arrhythmias, heart failure from cardiac involvement, and hypotension from autonomic dysfunction. Document the neurologic deficit before regional and treat the blood pressure as autonomically unsupported.

Time the case around bortezomib - Bortezomib causes peripheral neuropathy in 35% to 54% of IV-treated patients and thrombocytopenia in 16% to 52%, with a nadir on day 11 and recovery by day 21 of a 21-day cycle. It also causes hypotension in 8% to 9% and herpes zoster reactivation. Ask where in the cycle the patient is before booking an elective case that needs platelets.

Infection risk is real - MM patients are prone to infection, mostly pneumonia and pyelonephritis, and treatment adds neutropenia. Sterile technique on lines and blocks, and don't dismiss a recent respiratory illness as a cold.

Read the urine correctly - Bence Jones protein is undetectable on urine dipstick, which measures albumin, and requires immunofixation electrophoresis. A negative dipstick does not mean the kidneys are uninvolved.

Multiple myeloma (MM) is a clonal plasma cell proliferation producing monoclonal immunoglobulin, diagnosed by end-organ damage summarized as CRAB: hypercalcemia, renal dysfunction, anemia, and bone pain with lytic lesions. Median age at diagnosis is about 70. Marrow occupation by the plasma cell clone causes anemia (present in roughly three-quarters at diagnosis), thrombocytopenia and leukopenia. Myeloma cells activate osteoclasts and suppress osteoblasts, producing lytic bone that fractures pathologically and vertebrae that collapse, sometimes onto the cord. Circulating free light chains overwhelm proximal tubular reabsorption and precipitate as casts - cast nephropathy is the commonest renal injury, hypercalcemia second. Excess monoclonal immunoglobulin also causes hyperviscosity and platelet dysfunction, giving neurologic derangement and bleeding.