Multiple myeloma, Acute on

CRF, Sepsis 2° to line infection

Adi Asraf b Yusof
Patient’s detail
 Name: JM
 R/N: 683916
 Age: 55 years old
 Gender: Male
 Race: Malay
 Date of admission: 12/4/2011
Chief Complaint
 Referred from H. Jengka for IJC insertion
 Admitted to H. Jengka for c/o of lethargy,

vomiting x 2/7, LoW for 8/12

HoPI
 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
Past Medical Hx
 h/o MVA in 1980’s
 Deformed right lower leg
Past Medication Hx
 None
Social & Family Hx
 Active smoker
 Work as peneroka
 Widower with 6 children
 Family hx of hypertension
 No family hx of malignancy, bleeding

tendency
Review of System
 BP: 106/97 mmHG
 PR: 90 p/min
 RR: 20 b/min
 sPO2: 97% ↓RA
 T°C: 37°C
Diagnosis/Impression
 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
Lab Investigation
 Vital Sign
38.5
IV Ceftriaxone 1g OD
IV Amikacin 250mg OD
38
IV Cloxacillin 1g
BP; HR; Temp.

37.5 QID

37
Temp.
36.5
C. Cloxacillin
D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 1gD13
QIDD14 D15 D16 D17 D18 D19 D20 D21 D22

Day

160

140

120

100

80

60

40

20

0
D1 D2 D3 D5 D7 D9 D11 D13 D14 D16 D18 D20 D21

Systolic BP Diastolic BP Heart Rate

 Full Blood Count
Parameters Range D1 D4 D6 D10 D14 D16 D18
anemia ?
TWBC 4-10 x 10.96 7.58 6.9 8.28 6.12 4.16 3.04 myeloma
10^9/L

Hb 13 - 17 g/dL 4.7 11.1 11.1 10 9.5 8.9 8.3

RBC 4.5 – 6.5 x 1.77 3.72 3.85 3.5 3.37 3.21 3.03
10^12/L

Platelets 150-406 x 71 91 89 103 83 95 97

Thrombocytopenia
? myeloma
10^9/L

MCV 83-103 fL 78.5 84.4 84 85 87.6 85.4 85.1

MCH
 Anemia 27-32
due toPG the multiple myeloma
26.6 27.8 29.8 28 28 28.4 28.3
 Anemia shows to be normochromic, normocytic based on lab
value.
 ↑ urea ? Rtenal
BUSE/Renal Profile failure

Parameters Range D1 D3 D4 D6 D10 D14 D16 D18

Urea 1.7-8.3 63 38.6 23.8 27.2 23.1 26.8 17.7 14.7

mmol/L

Na 135-145 115 122 132 126 133 129 133 134

mmol/L

K 3.5-5.0 6.6 20* 3.6 3.8 4.5 4.1 4.0 3.7

mmol/L

Cl 96-106 77 83 91 89 95 91 94 93
mmol/L

Ca 2.1-2.6 3.44 1.24* 2.51 2.43 2.25 2.44 2.51 2 53

↑ crea ? Renal
mmol/L ↑ PO4- ? Renal failure
failure
Mg 0.7-1.3 2.11 0.24 1.3 1.24 1.2 1.17 1.08 1.08
mmol/L

PO4- 0.8-1.45 2.56 1.51 1.36 1.63 1.91 2.47 2.02 1.71
mmol/L

SCr 64-122 µmol/L 1975 1231 852 982 926 1002 653 495
 Patient urea/creat still high despite the fact that the patient was on regular
ClCr ml/min 3.97 6.36 9.20 7.98 8.46 7.82 12.0 15.8
haemodialysis. However, it also shows a decreasing trend, suggesting that
maybe the patient is responding to the treatment.
 *contaminated sample - repeated
 hypoalbuminemia
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

↑ protein
ALT <32 µ/L 2 3 0 0 3 3 0 3? myeloma

 High protein most probably due to myeloma

 Coagulation profile
Parameters Range D1 D3 D10 D11
PT 10 – 13.5 72.3 14.5 15.9 16.8
s
APTT 26 - 42 s 121.9 36.1 31.1 57.4
INR < 1.5
Patient develop 10.5
tendency 1.3despite several
for bleeding 1.4 blood 1.5
transfusion.
 C&S Result
Date Sampling Source Result Sensitivity Resistant
D8 D2 Blood S.aureus Clindamycin Penicillin
Erythromycin
Gentamicin
Oxacillin
SMX/TMP
D14 D11 Synovial N.G. - -
fluid –
left knee
 In Ward Medication
Medication Date Started Date Stopped Indication
IV Ceftriaxone 1g stat then D2 D9
Sepsis
OD
IV Amikacin 250mg stat & D3 D5 Infective
OD endocarditis
IV Cloxacillin 1g TDS D9 D9
IV Cloxacillin 1g QID D9 D12 Sepsis
C. Cloxacillin 500mg QID D12
IV Omeprazole 40mg OD D1 D6 Stress ulcer
T. Omeprazole 40mg OD D6 prophylaxis

IV Vitamin K 10mg stat & OD D3 D6 Haemorrhage

Medication Date Started Date Stopped Indication
Liniment Methyl D6
Salicylate
IM Tramadol 50mg D9 D9
Arthritis pain
stat
T. PCM 1g TDS D10 D12
Fastum Gel BD D14
IV Dexamethasone D14 D16
4mg TDS x 4/7
IV D16
Cyclophosphamide
200mg weekly
Multiple Myeloma
T. Thalidomide D14
100mg OD
IV Dexamethasone D16
8mg x 2/7, then D8
to D11

IV Granisetron 3mg D16 D16

Pharmaceutical Care Issue
 Multiple Myeloma
 Sepsis 2° to line infection
 PCI 1: Multiple Myeloma
 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.
Durie-Salmon Criteria for MM
Diagnosis
Chemotherapy Protocol
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)

Ampang Protocol v1.2011

 Comment
•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).
 PCI 2: Sepsis
 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.
Management

National Antibiotic Guidelines 2008

 Comment
The empirical therapy does not follow the
guideline, however pt condition improved as
Ceftriaxone is a broad spectrum antibiotic.
Patient temperature resolved – afebrile
Patient TWBC shows decreasing trend
Once C&S result obtained, IV Ceftriaxone was

off, and IV Cloxacillin 1g QID was started.

Drug Related Problem
 DRP 1
Drug Related Inappropriate frequency of IV Cloxacillin
Problem (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 2
Drug Related Drug with narrrow therapeutic index-
Problem 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 3
Drug Related Inappropriate regimen of IV Dexamethasone
Problem 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 4
Drug Related Inappropriate empirical therapy for infective
Problem 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 5
Drug Related Inappropriate empirical therapy for sepsis
Problem
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.
Conclusion
 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
References
 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.