clinical 1 - multiple myeloma
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Multiple myeloma, Acute on CRF, Sepsis 2° to line
infectionAdi Asraf b Yusof
Name: JM R/N: 683916 Age: 55 years old Gender: Male Race: Malay Date of admission: 12/4/2011
Patient’s detail
Referred from H. Jengka for IJC insertion Admitted to H. Jengka for c/o of lethargy,
vomiting x 2/7, LoW for 8/12
Chief Complaint
Admitted to ward for anemia (Hb: 7.5 mg/dL)
Upon Ix, serum urea & creatinine found to be high
PD done in H. Jengka (23/3/11, 1/4/11) – 80 cycles
However, persistent ↑ serum urea/creat despite PD
HoPI
h/o MVA in 1980’s Deformed right lower leg
Past Medical Hx
None
Past Medication Hx
Active smoker Work as peneroka Widower with 6 children Family hx of hypertension No family hx of malignancy, bleeding
tendency
Social & Family Hx
BP: 106/97 mmHG PR: 90 p/min RR: 20 b/min sPO2: 97% ↓RA T°C: 37°C
Review of System
Persistent reduction of Hb despite blood transfusion
Unresolved increase of serum urea/creat Mitral stenosis TRO IE Multiple myeloma Acute on CRF Sepsis 2° to line infection Left knee arthritis Upper & Lower motor neuron weakness
Diagnosis/Impression
Lab Investigation
D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 D16 D17 D18 D19 D20 D21 D2236.436.636.8
3737.237.437.637.8
3838.2
Temp.
Day
BP
; H
R;
Tem
p.
Vital SignIV Ceftriaxone 1g ODIV Amikacin 250mg OD
IV Cloxacillin 1g QID
D1 D2 D3 D5 D7 D9 D11 D13 D14 D16 D18 D20 D210
20
40
60
80
100
120
140
160
Systolic BP Diastolic BP Heart Rate
C. Cloxacillin 1g QID
Full Blood CountParameters Range D1 D4 D6 D10 D14 D16 D18
TWBC 4-10 x 10^9/L 10.96
7.58 6.9 8.28 6.12 4.16 3.04
Hb 13 - 17 g/dL 4.7 11.1 11.1 10 9.5 8.9 8.3
RBC 4.5 – 6.5 x 10^12/L
1.77 3.72 3.85 3.5 3.37 3.21 3.03
Platelets 150-406 x 10^9/L
71 91 89 103 83 95 97
MCV 83-103 fL 78.5 84.4 84 85 87.6 85.4 85.1
MCH 27-32 PG 26.6 27.8 29.8 28 28 28.4 28.3
Anemia due to the multiple myeloma Anemia shows to be normochromic, normocytic based on lab
value.
anemia ? myeloma
Thrombocytopenia? myeloma
BUSE/Renal Profile
Parameters Range D1 D3 D4 D6 D10 D14 D16 D18
Urea 1.7-8.3 mmol/L 63 38.6 23.8 27.2 23.1 26.8 17.7 14.7
Na 135-145 mmol/L
115 122 132 126 133 129 133 134
K 3.5-5.0 mmol/L 6.6 20* 3.6 3.8 4.5 4.1 4.0 3.7
Cl 96-106 mmol/L 77 83 91 89 95 91 94 93
Ca 2.1-2.6 mmol/L 3.44 1.24* 2.51 2.43 2.25 2.44 2.51 2 53
Mg 0.7-1.3 mmol/L 2.11 0.24 1.3 1.24 1.2 1.17 1.08 1.08
PO4- 0.8-1.45 mmol/L
2.56 1.51 1.36 1.63 1.91 2.47 2.02 1.71
SCr 64-122 µmol/L 1975
1231 852 982 926 1002 653 495
ClCr ml/min 3.97 6.36 9.20 7.98 8.46 7.82 12.0 15.8
Patient urea/creat still high despite the fact that the patient was on regular haemodialysis. However, it also shows a decreasing trend, suggesting that maybe the patient is responding to the treatment.
*contaminated sample - repeated
↑ urea ? Rtenal failure
↑ crea ? Renal failure↑ PO4- ? Renal
failure
High protein most probably due to myeloma
Liver profile
Parameters Range D1 D3 D4 D6 D10 D14 D16 D18
Albumin 35 – 50 g/L 20.5 23.5 22.9 22.1 22.2 22.2 21.2 21.8
T. Bilirubin <20 µmol/L 8.8 9.8 14 8.9 8.3 7.7
T. Protein 66 – 87 g/L 97.4 85.9 89 91.6 90 92 90 91
ALP 53 – 141 µ/L 61 0 61 54 56 51 50 53
ALT <32 µ/L 2 3 0 0 3 3 0 3
hypoalbuminemia
↑ protein ? myeloma
Coagulation profile
Parameters
Range D1 D3 D10 D11
PT 10 – 13.5 s
72.3 14.5 15.9 16.8
APTT 26 - 42 s 121.9 36.1 31.1 57.4
INR < 1.5 10.5 1.3 1.4 1.5Patient develop tendency for bleeding despite several blood transfusion.
C&S Result
Date Sampling Source Result Sensitivity Resistant
D8 D2 Blood S.aureus ClindamycinErythromycinGentamicinOxacillinSMX/TMP
Penicillin
D14 D11 Synovial fluid – left knee
N.G. - -
Medication Date Started
Date Stopped
Indication
IV Ceftriaxone 1g stat then OD
D2 D9 Sepsis
IV Amikacin 250mg stat & OD
D3 D5 Infective endocarditis
IV Cloxacillin 1g TDS D9 D9
SepsisIV Cloxacillin 1g QID D9 D12
C. Cloxacillin 500mg QID D12
IV Omeprazole 40mg OD D1 D6 Stress ulcer prophylaxisT. Omeprazole 40mg OD D6
IV Vitamin K 10mg stat & OD
D3 D6 Haemorrhage
In Ward Medication
Medication Date Started Date Stopped Indication
Liniment Methyl Salicylate
D6
Arthritis painIM Tramadol 50mg stat
D9 D9
T. PCM 1g TDS D10 D12
Fastum Gel BD D14
IV Dexamethasone 4mg TDS x 4/7
D14 D16
Multiple Myeloma
IV Cyclophosphamide 200mg weekly
D16
T. Thalidomide 100mg OD
D14
IV Dexamethasone 8mg x 2/7, then D8 to D11
D16
IV Granisetron 3mg stat (before chemo)
D16 D16 Anti-emetic
Multiple Myeloma Sepsis 2° to line infection
Pharmaceutical Care Issue
A plasma cell dyscrasia characterized by a clonal proliferation of lymphoid B cells & bone marrow infiltration by plasma cells.
Common manifestation include bone pain, renal insufficiency, hypercalcemia, anemia and recurrent infections.
PCI 1: Multiple Myeloma
Durie-Salmon Criteria for MM Diagnosis
VCD protocol• IV Bortezomib 1.3mg/m² (D1, 4, 8, 11)•IV Cyclophosphamide 250mg/m²•IV Dexamethasone 20mg BD (D1 & 2, 4 & 5, 8 &9, 11 & 12)(Thal/Dex) protocol•Thalidomide 200mg OD•T. Dexamethasone 40 mg/day (D1-D4)
Chemotherapy Protocol
Ampang Protocol v1.2011
•Dose of IV Dexamethasone is only 4mg TDS initially and do not comply to the guideline.•On D3 of therapy it was increased to 8mg TDS, but still lower than the dose suggested in guideline.•Thalidomide dose also lower than suggested in the protocol which should be 200mg OD.• Pt to be started on IV Bortezomib in Hosp Ampang (KIV this week).
Comment
Infection accompanied by acute inflammatory reaction with systemic manifestation – release of endogenous mediator of inflammation -> bloodstream
Common pathogens include staphylococci, gram –ve organisms & meningococci
Pt typically had fever, tachycardia & tachypnea.
PCI 2: Sepsis
Management
National Antibiotic Guidelines 2008
The empirical therapy does not follow the guideline, however pt condition improved as Ceftriaxone is a broad spectrum antibiotic.Patient temperature resolved – afebrilePatient TWBC shows decreasing trendOnce C&S result obtained, IV Ceftriaxone was off, and IV Cloxacillin 1g QID was started.
Comment
Drug Related Problem
DRP 1
Drug Related Problem
Inappropriate frequency of IV Cloxacillin (TDS)
Justification Appropriate freq for IV Cloxacillin is 6 hourly or in 4 divided dose for MSSA infection. (Lexicomp Drug Information Handbook, National Antibiotic Guidelines 2008)
Recommendation - To start IV Cloxacillin 1g QID instead of TDS.
Outcome - IV Cloxacillin 1g QID was started on D9. Recommendation by pharmacist was noted on the med chart.
DRP 2Drug Related Problem
Drug with narrrow therapeutic index- Amikacin
Justification -TDM should be done to assess therapeutic effects /toxic effects of drug with narrow therapeutic index (i.e. aminoglycosides - amikacin)- Therapeutic range: Cpre: <10mg/L, Cpost: 20-30 mg/L- Toxicity if: Cpre: >10mg/L, Cpost: >35mg/L
Recommendation - To send pre & post level for IV Amikacin after the third dose is completed
Outcome - IV Amikacin was stopped on D5, right after the third dose, plus no TDM level was done.
DRP 3Drug Related Problem
Inappropriate regimen of IV Dexamethasone for treatment of multiple myeloma
Justification -Based on Ampang Protocol, the dose should be 20mg BD on D1 & 2, 4 & 5, 8 & 9, 11 & 12
Recommendation - To increase the dose of IV Dexamethasone to 20mg BD, & to revise the frequency of IV Dexamethasone given.
Outcome -IV Dexamethasone was changed to 8mg TDS on D3 of therapy, and to be continued on D8-D11
-Still below the dose suggested by the guideline plus the dosing frequency does not follow the guidelines.
DRP 4Drug Related Problem
Inappropriate empirical therapy for infective endocarditis
Justification Based on the National Antibiotic Guidelines, the empirical therapy consist of:
Recommendation To give IV Cloxacillin 2g 4 hourly plus IV Gentamicin instead of IV Amikacin.
Outcome IV Amikacin was stopped on D5. IE was ruled out on D9, after ECHO had been done. IV Cloxacillin was only started on D9, after C&S result came back, indicated for sepsis.
DRP 5Drug Related Problem
Inappropriate empirical therapy for sepsis
Justification Based on the National Antibiotic Guidelines 2008, the empirical therapy for sepsis 2° to line infection is IV Cloxacillin 100mg/kg/24H in 4 divided doses
Recommendation Suggest to give IV Cloxacillin 1g QID instead of IV Ceftriaxone
Outcome IV Cloxacillin was started on D9, after the blood C&S result was received, and IV Ceftriaxone was discontinued.
Pt currently still in ward Alert but lethargic Unable to remove lower leg – due to lower
motor neuron weakness KIV to transfer to Hosp Ampang, for starting
IV Bortezomib (Velcade®) there. Despite the high level of serum urea/creat, pt
probably were showing sign of responding to the treatment due to the decreasing trend:◦ Urea:63 -> 14.7 mmol/L◦ Creatinine: 1975 -> 495 µmol/L
Conclusion
MICROMEDEX® Healthcare Series Vol. 143 (1974-2008)
National Antibiotic Guidelines 2008 Ampang Protocol V1.2011, Haematology Department,
Hosp. Ampang Myeloma Management Guidelines, Brian G.M. Durie et.
al., The International Myeloma Foundation Harrison Manual of Oncology, Bruce A. C., Thomas J.
L., Dan L.L., McGraw Hill Medical Merck Manual of Medical Information (2nd Home ed.),
2003, Merck & Co, Inc. Manual of Laboratory & Diagnostic Test, Wilson D. D.,
McGraw Hill.
References
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