1/11. Biclonal gammopathy in multiple myeloma: a case report.Monoclonal gammopathy is a group of B-cell disorders which result in the production of a specific and unique monoclonal immunoglobulin (M-component). Biclonal gammopathy is characterized by the simultaneous appearance of two different M-components. The incidence is about 1% of all monoclonal gammopathy. This paper reports on a 48-year-old male who had a chief complaint of back-pain beginning 7 months earlier. A physical examination was unremarkable, except for anemia and tenderness in the back. Hemoglobin was 5.4 g/dl, white blood cells 4.5 x 10(3)/microliter, platelets 157 x 10(3)/microliter, and reticulocytes 0.9%. serum iron was 79 mg/dl, and total iron-binding capacity was 210 mg/dl. A blood smear showed the formation of rouleaux, but no plasma cells were found. serum creatinine was 5.4 mg/dl, with a creatinine clearance of 18.1 ml/min. serum electrolytes were normal except for serum calcium which was 14.4 mg/dl. The urinalysis showed strongly positive proteinuria ( 2), with negative bence jones protein. serum protein electrophoresis showed an increase and a spike pattern of beta-2 globulin (2.8 g/dl) and alpha-2 globulin (1.5 g/dl), with normal gamma globulin. By nephelometry technique, serum IgG was normal (1388 mg/dl), IgA was high (900 mg/dl), and IgM was also high (517 mg/dl). Advanced and extensive osteolytic lesions were found in the clavicle, ribs, skull, humerus, femur, and columna vertebralis. plasma cells (myeloma cells) in bone marrow were 32%. The clinical diagnosis was multiple myeloma (biclonal gammopathy) stage IIIB (Durie and salmon staging system). Clinical response was good after two series of conventional chemotherapy, with normal serum electrophoresis, decreasing serum creatinine and serum calcium. Based on the above data, the diagnosis of multiple myeloma with biclonal gammopathy was confirmed. This is a rare case with a combination of IgA and IgM M-components.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
2/11. Bone marrow aspirates as part of routine donor assessment for allogeneic blood and marrow transplantation can reveal presence of occult hematological malignancies in otherwise asymptomatic individuals.Pre transplant screening work-up of donors for allogeneic blood and marrow transplantation is essential in an effort to minimize risks to the recipient and protect the donor. At Princess Margaret Hospital, every potential donor is screened with a bone marrow aspirate. The case histories of three asymptomatic potential donors who presented within 1 year with normal complete blood counts, history and physical examination are presented. A 65-year-old male patient was diagnosed with smouldering multiple myeloma, a 72-year-old male patient with chronic lymphocytic leukemia and a 42-year-old male patient with myelodysplastic syndrome. bone marrow examination led to the diagnosis in each one of these cases. Of note is that each of the potential donors was discovered to have the same disease as the transplant recipient. in vitro clonogenic hemopoietic progenitor assays were compared to those of 20 normal volunteers. Inferior growth of hemopoietic progenitor colonies in all three was noted. In conclusion, particularly in older donors and donors with potential for familial malignancies, more screening investigations including bone marrow aspiration may be reasonable to investigate for occult hematological malignancies prior to stem cell donation. Clonogenic assays can contribute to detect hemopoietic abnormalities pre transplant.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
3/11. Simultaneous bilateral trochanteric fractures during squatting in a patient with multiple myeloma.Pathologic bone fractures are usually confined to the trunk in multiple myeloma (MM). But bilateral trochanteric fractures have not been reported in patients with MM before. Radiographic, histological and immunoelectrophoresis revealed typical features of MM. This report points out the importance of physical rehabilitation of patients in addition to chemotherapy in adaptation to the activities of daily living.- - - - - - - - - - ranking = 0.084574308506376keywords = physical (Clic here for more details about this article) |
4/11. High levels of doxorubicin in the tissues of a patient experiencing extravasation during a 4-day infusion.A 56-year-old patient with multiple myeloma experienced an extravasation of doxorubicin (DOX) and vincristine administered as a 96-hour infusion. An unknown quantity of solution (2.1 mg/ml of DOX and 0.1 mg/ml of vincristine) extravasated into the medial aspect of the right upper arm. This was caused by the axillary blockage of a 14-inch, 18-gauge catheter that had been inserted through the antecubital fossa. The only physical complaint mentioned by the patient was a dull muscle ache. No local swelling or redness was apparent until 2 weeks after the extravasation occurred, at which time surgical debridement yielded a 9.2 x 4 x 2-cm section of fascia and thrombosed vein with a normal-appearing margin. A high performance liquid chromatography analysis of different tissue areas in the surgical specimen yielded DOX levels of 1.25 to 7.94 micrograms/g of wet tissue weight. These levels are approximately tenfold higher than those of any previous extravasation reports. Slightly lower levels of the DOX aglycone (but no doxorubicinol) were recovered from these tissues. An important finding was the DOX level of 2.7 micrograms/g in the margin of the specimen, predicting a need for further surgery. Indeed, a second debridement was performed 1 week later, followed by a split thickness skin graft. Although the myeloma remains in clinical remission, use of the effected right arm is limited primarily by skin contracture at the graft site. This case demonstrates that high DOX levels can be deposited in soft tissues during prolonged DOX infusions without producing severe acute symptomatology. Furthermore, an analysis of DOX content in excised tissues may help guide the surgical management of the patient experiencing an extravasation.- - - - - - - - - - ranking = 0.084574308506376keywords = physical (Clic here for more details about this article) |
5/11. Spinal pain made worse by recumbency: a clue to spinal cord tumors.In the absence of physical findings, pain in the low back, cervical or thoracic spine, or the extremities presents a diagnostic problem. On occasion the pain is present or made worse only when the patient lies down. We have attended four patients with underlying extradural tumors of the spinal canal. A 75-year-old woman with chronic back pain was treated for multiple myeloma with intravenous dexamethasone and 400 rads of x-ray irradiation to the lumbar spine and experienced marked pain relief in 24 hours. A 76-year-old woman with neck pain had complete pain relief after a vascular, calcified meningioma was removed surgically from under the 2nd and 3rd cervical nerve roots. A 38-year-old male with constant pain in the lumbar area and right leg and foot experienced marked relief from pain after a neurolemmoma of the cauda equina was surgically removed. A 57-year-old woman with knee pain became pain free 24 hours after radiation therapy to an enlarged nodular cauda equina. These four cases illustrate a diagnostic clue rarely mentioned in the literature.- - - - - - - - - - ranking = 0.084574308506376keywords = physical (Clic here for more details about this article) |
6/11. Histiocytic lymphoma of the ileocecal region after chemotherapy for multiple myeloma.Histiocytic lymphoma of the ileocecal region developed in a patient with multiple myeloma following successful long-term alkylating agent therapy. Five and one-half years after the diagnosis of myeloma, while in remission on cyclophosphamide therapy, the patient experienced severe abdominal right lower quadrant pain due to a large cecal lymphoma. A right hemicolectomy was performed with relief of symptoms. However, 9 months later, while still asymptomatic, routine physical examination revealed a recurrent right lower quadrant tumor. radiation therapy decreased the size of the mass, but five months later partial small bowel obstruction occurred because of recurrent lymphomatous infiltration. The patient died 7 years after the diagnosis of myeloma with extensive abdominal lymphoma. There was no evidence of recurrent myeloma after the initial remission on cyclophosphamide therapy. This patient adds to the growing literature of a second malignancy occurring after prolonged successful chemotherapy of a primary neoplasm.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
7/11. amyloidosis presenting as a mass in the neck.A 54-year-old white male presented with a large suprahyoid midline mass. On thorough history and physical examination, he had features which characterize amyloidosis, including congestive heart failure and carpal tunnel syndrome. The classification, clinical findings, and associated syndromes are reviewed. A striking feature of the amyloid deposit is its rapid growth. amyloidosis should now be considered in a differential diagnosis of a neck mass.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
8/11. Renal biopsy diagnosis of clinically silent multiple myeloma.Acute renal failure due to multiple myeloma is uncommon but may be the presenting feature of the disease. When it occurs, the underlying multiple myeloma is usually easily diagnosed by the presence of a serum M protein, hypercalcemia, skeletal pain, or typical bone lesions. We report here four cases of patients who, at the time they developed acute renal failure, had none of these findings nor any other historical or physical evidence of multiple myeloma. A renal biopsy in all four cases revealed the typical diagnostic features of "myeloma kidney" and led to confirmation of the diagnosis by bone marrow examination. Tamm-Horsfall protein was identified within myeloma casts and the glomerular urinary space, suggesting that tubular obstruction and retrograde urine flow precedes the development of "myeloma kidney" and acute renal failure.- - - - - - - - - - ranking = 0.084574308506376keywords = physical (Clic here for more details about this article) |
9/11. multiple myeloma and gastric carcinoma. Possible late effects of limited abdominal X-irradiation.A man, aged 34, was treated in 1954 for duodenal ulcer by antroduodenectomy followed by X-irradiation to the stomach in a dose of 2,000 rads. Over two decades, he developed several conditions attributable to the previous irradiation, including the physical appearances of premature ageing, shrinkage of the left kidney due to irradiation nephritis, immune deficiency, multiple myeloma of IgA type, and lastly, carcinoma of the stomach. The kidneys, especially the left, the bone marrow and stomach would have been in the field of X-irradiation. These effects of local X-irradiation are discussed in relation to the known effects of total body irradiation in causing decreased longevity in animals and inducing cancer in man.- - - - - - - - - - ranking = 0.084574308506376keywords = physical (Clic here for more details about this article) |
10/11. A 45-year-old woman with right shoulder pain.The following case is presented to illustrate the roentgenographic and clinical findings of a condition of interest to the orthopedic surgeon. Initial history, physical findings, and roentgenographic examinations are found on the first page. The final clinical and roentgenographic differential diagnoses are presented on the following pages.- - - - - - - - - - ranking = 0.084574308506376keywords = physical (Clic here for more details about this article) |
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