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NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds Clinical Vignette. Ankit Parikh MD, PGY-2 January 6, 2009. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint.

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NYU Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Ankit Parikh MD, PGY-2 January 6, 2009 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint A 69-year-old man with relapsed multiple myeloma was referred for consultation regarding allogeneic hematopoietic stem cell transplantation from his HLA-identical brother. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  3. History of Present Illness • Four years ago, the patient was incidentally found to have an increased protein level on laboratory assessment; he was asymptomatic. • Work-up led to the diagnosis of smoldering myeloma. • The patient remained in his usual state of health until one year later, when the patient had a rapid increase of his IgG level to 5,630 mg/dl. • Further testing, including a bone marrow biopsy, demonstrated an increase in plasma cells to 60% (normal <10%). UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  4. History of Present Illness • A skeletal survey demonstrated no lytic or blastic lesions • A total spine MRI was consistent with diffuse myeloma involvement with a heterogeneous pattern and a focal lesion at the level of T12. • Free kappa to lambda ratio was 18.86 (normal 0.26-1.65). • Urine immunofixation showed IgG kappa bands. • The decision was made to start the patient on chemotherapy. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  5. History of Present Illness • His initial treatment consisted of the BiRD regimen: clarithromycin (Biaxin), lenalidomide (Revlimid), and dexamethasone for four cycles. • The patient had a good response with a decline of his protein level. • Treatment was complicated by the development of bilateral deep venous thromboses. • The decision was made to proceed with autologous stem cell transplantation. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  6. History of Present Illness • Autologous stem cell transportation was undertaken two years prior to the current presentation. • The patient achieved complete remission by bone marrow biopsy and protein electrophoresis. • The patient remained in remission for one year. • Subsequently, he was diagnosed with relapsed disease and started on lenalidomide (Revlimid), bortezomib (Velcade), and dexamethasone. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  7. History of Present Illness • At the time of referral for allogeneic stem cell transplantation, the patient had completed four cycles of lenalidomide, bortezomib, and dexamethasone. • He has been continued on lenalidomide maintenance of 15mg daily. • Recent workup showed that the patient has achieved a good partial response. • The patient otherwise has no complaints and is accompanied by his HLA-identical brother.

  8. Additional History • Past Medical History • Multiple Myeloma • Papillary Urothelial Neoplasm of • Low Malignant Potential • Hypertension • Hyperlipidemia • Celiac Disease • Depression/Anxiety • Past Surgical History • Fulguration of bladder neoplasm • Hiatal hernia repair • Bilateral cataract surgery • Family History • Non-contributory • Social History • Retired executive • Lives with wife • Ex-smoker • Social alcohol use • Denies illicit drug use • Gluten-free diet UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  9. Outpatient Medications Lenalidomide 15 mg daily Acyclovir 200 mg twice daily TMP/SMX 800/160 mg three times/week Fluconazole 100 mg daily Atenolol 25 mg daily Simvastatin 40 mg daily Escitalopram 5 mg daily Alprazolam 0.25 mg daily Temazepam 15 mg at bedtime prn Oxycodone/Acetaminophen prn Allergies: No known drug allergies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  10. Physical Examination General: Well-appearing man in no acute distress Vital Signs: T 36.7 C, BP 112/76, HR 63, RR 18 His physical examination was unremarkable. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  11. Laboratory Findings • CBC: • Hemoglobin 10.4 g/dl • The remainder of the CBC was within normal limits • Basic metabolic panel: • Creatinine 1.4 mg/dl • The remainder of the BMP was within normal limits • Hepatic panel: Within normal limits UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  12. Laboratory Findings • Immunofixation:IgG kappa monoclonal gammopathy • Protein electrophoresis: M-spike of 0.2 g/dl • Bone marrow examination:Plasma cells 10% with otherwise trilineagehematopoiesis UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  13. Diagnosis Relapsed IgG kappa Multiple Myeloma UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  14. Therapeutic Plan T-cell depleted, reduced-intensity allogeneic stem cell transplantation from an HLA-identical sibling UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

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