MULTIPLE MYELOMA

 I often go through my case files to take note of interesting cases, which I could open up (name concealed) to the world in a language, which is very comprehensible and has an important health message to deliver. One such case was of a young, healthy man with a disease called multiple myeloma! A year back, a young 40-year-old healthy-looking gentleman was referred to me, by an orthopedician friend of mine. He had been complaining of niggling back pain for a month, but only saw an orthopedician after prolonged pestering by his wife. He did admit the pain was getting worse by the day. He agreed to see the doctor only when the pain was just unbearable! The doctor immediately asked for an Xray of the spine and explained to him the possibility of a pathological fracture in two of his lower thoracic vertebrae. The back pain he was told was in all probability due to the outgoing nerves being compressed by the damaged vertebrae. He suspected multiple myeloma, and that’s the reason, the distressed family was referred to me, a hemato-Oncologist. I could guess, they have probably scanned the entire “Google world” about multiple myeloma, before coming to me. They looked really worried, with a valid reason too. Multiple myeloma is blood cancer, which can affect the young too. It can be very crippling, especially in those with severely damaged bones and deranged kidney functions. After all, he was only 42 years old and had a whole family to look after, along with his elderly parents who were retired and under medical supervision themselves.

I asked them to do a battery of tests and see me back with all the results. I told them that the referring doctor was probably right in suspecting multiple myeloma considering the patient looked pale (occurs when haemoglobin is low) and had a vertebral fracture, making the possibility of a diagnosis of multiple myeloma highly likely.

He also had several other complaints like that of a sense of increasing constipation, tiredness and intermittent vomiting. I looked at the results and explained the family by trying to correlate his complaints to the results available with me. The weakness was related to your low haemoglobin and the extremely high calcium in his blood, I explained to him. Constipation and intermittent vomiting were also related to high blood calcium and an abnormal kidney function due to the primary disease. I further explained the need for specific tests like a bone marrow examination that is required to check the percentage of the abnormal plasma cells in the bone. The special genetic analysis would help in determining the aggressiveness of the disease.

I explained to them that several genetic mutations cause myeloma and this is reflected with an abnormal protein in the blood, something that is identified in the blood by either an “M band” or an abnormal free light chain ratio. It is this protein which causes all the damage to the kidney functions. It also leads to an abnormally high efflux of the calcium out from the bones into the bloodstream, weakening the bones and adding to the patient’s dehydration. This high calcium in the bloodstream also causes further damage to the kidneys. I mentioned to him about the dreaded “CRAB” of myeloma – High Calcium in blood, Renal (kidney) damage, Anaemia (low haemoglobin – related to the number of abnormal cells in the bone) and Bony diseases- like the vertebral fracture this patient has had. Unfortunately, this patient had all of it.

As I described his disease in detail, he went from being confused to despair and later depression. My debts, my family, my children, he mentioned to me. Who shall take care if anything happens to me? Just to make him feel any better, I mentioned to him that he had a disease similar to a very famous and beautiful personality – Lisa Ray. She got better and so shall u, I told him! But this did not comfort him. Our team finally convinced him to initiate chemotherapy. I told him since he had a t (4; 14) genetic abnormality, his likelihood of a good response would be best with bortezomib (chemotherapy) based therapy. The initial few weeks were very intense. I was planning chemotherapy to intermittent sessions of dialysis, blood transfusions and two episodes of pneumonia with near death. He had it all. But our team of nephrologists, haematologists, resident doctors and nurses did everything to get him better. He got four such rounds of therapy, each lasting for a month. It took him five long months to complete all his chemotherapy sessions. He did develop few complications with intermittent diarrhoea and a feeling of loss of sensation in his both feet.

A repeat assessment of the laboratory parameters, after completing the therapy showed him in a state of complete remission, with no detectable disease in his body. I told him it would be best to undergo an autologous stem cell transplant (ASCT) and that doing so would help me keep the disease at bay for much longer. He did undergo an ASCT. In fact, he received his own extracted stem cells. As thrilling and exciting as it sounded, it was a month-long procedure wherein he received certain growth factors injections, which helped his own blood stem cells to come out into the peripheral blood from the bone marrow. These blood stem cells were collected through a special apheresis machine, and later reinfused back into him after high dose chemotherapy with a drug called melphalan. It took him several weeks to recover his depleted blood counts. He also developed one episode of fever requiring prolonged antibiotics but recovered well from the procedure. He survived the drilling six months with the excellent support from his family, friends and our entire haematology/nephrology and nursing team. His back pain, of course, improved, without the need for any surgery, though he did complain he was a little shorter in height due to the collapse in his vertebrae, but pain-free. He is now on regular close follow up.

Multiple myeloma is often missed due to its unique presentations and should always be kept as a potential diagnosis in any patient presenting with back pains, kidney damage and a pallor (low haemoglobin). Most cases often are referred to either an orthopedician or a nephrologist for their complaints of back pain and damaged kidney functions. A timely referral to a haemato-oncologist greatly influences the disease outcomes.