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