Question

56 year old lady who was first referred to the hospital complaining of low back pain radiating to the left leg. She noted that her left leg had been more swollen than usual below the knees for the past 4 months, she felt tired all the time and said he muscles felt tender. investigators at this time showed a raised serum calcium (2.73mmol/l) and decreased serum albumin (28g/l). the patient was found to have proteinuria. urinalysis and electrophoresis showed a monoclonal igG band-this is one of the characteristics findings of myeloma. additional investigation showed a proteinuria of 11g/25hrs and decreased creatinine clearance.
-JVP raised
-Oedema of legs and abdominal wall noted.
-pericardial rub present plus other signs suggesting a right pleural effusion.
Investigation:
-chest x-ray confirmed right sided pleural effusion.
-Echocardiography showed moderate left ventricular hypertrophy with poor left ventricle function.
Patient became acutely I'll with hypotension (systolic BP 50mmHg). Patient suffered cardiac arrest afterwords, she was resuscitated, transferred to ICU where she had another cardia arrest from which she could not be resuscitated.
-What do you think the cause of death was?
-What were the signs and symptoms?

Answer 1

The cause of death here is Congestive heart failure

Diagnosis is : Multiple myeloma leading to Renal failure and Congestive heart failure

Here, the patient has features of renal failure [proteinuria, hypoalbuminemia] and cardiac failure [raised JVP, edema, right sided pleural effusion, left ventricular hypertrophy]

The presence of monoclonal IgG band in electrophoresis is consistent with a diagnosis of Multiple myeloma.

Pathophysiology : Renal failure is a complication in patients with multiple myeloma  is caused by the precipitation of immunoglobulin light chains, which form casts in the renal tubules leading to obstruction. Renal failure can result in fluid retention and hypertension , leading to left ventricular hypertrophy and cardiac failure.

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Multiple myeloma is a hematological malignancy affecting the plasma cells. The plasma cells are the antibody secreting cells of the immune system. The myeloma cells accumulate in the bone marrow, leading to deficiencies of other bonemarrow elements causing anemia, leukopenia and thrombocytopenia. It also causes destruction of the bone leading to bone pain and pathological fractures. Bone destruction can result in Hypercalcemia. The abnormal plasma cells, secrete a monoclonal population of immunoglobulin light chains, which appears in urine- known as Bence jones proteinuria. This can also obstruct the renal tubules laeding to renal failure.

Signs and symptoms - Multiple myeloma

Symptoms	Signs
Recurrent infections	Anemia
Fatigue , Bone pain	Bone tenderness
Unexplained fractures	Signs of hypercalcemia
Weight loss	Signs of renal failure
Constipation	Pathologic fractures

Signs and symptoms - Congestive heart failure

Symptoms	Signs
Dyspnoea	Dependent edema
Exertional dyspnoea	Elevated Jugular venous pulse
Orthopnoea	Ascites, pleural effusion
Edema	Hepatomegaly
Fatigue	Tachycardia, S3 gallop