CASE PRESENTATION:
Complaints during jan 2021.
Patient was apparently asymptomatic 1 yr back ,she came with chief complaint of chest pain since 6 months pricking type ,non radiating subsiding on its own.
She also complained of SOB since 1month,which was insidious in onset and gradually progressed to grade 4(dyspnea at rest).
H/o orthopnea and palpitations.
Decreased appetite since 20 days.
Generalised weakness since 15 days.
Patient complained of non radiating epigastric pain since 10 days.
B/L lower limb pitting type of oedema since 5 days which then spread to upper limbs and face.
PAST HISTORY:
No H/o DM,HTN,TB,ASTHMA EPILEPSY, Thyroid abnormalities.
PERSONAL HISTORY:
Sleep - adequate
Appetite reduced since 20 days.
BB normal
Addictions -tobacco chewing for a period of 6months, occasional alcoholic.
GENERAL EXAMINATION:
Moderately built, moderately nourished.
Pallor present
Icterus cyanosis clubbing lymphadenopathy absent
Temp - 98.6 F
PR - 108 bpm
BP - 120/70 mm of Hg
Spo2 - 98% room air.
CVS EXAMINATION:
On inspection raised JVP is seen.
On palpation apical pulse is diffused.
Parasternal Heave present.
On auscultation s1 s2 heard,muffled murmurs heard.
ABDOMEN EXAMINATION:
On inspection distended abdomen with multiple hemorrhagic spots.
On palpation Tenderness over epigastric region and right hypochondrium.
Hepatosplenomegaly present.
PROVISIONAL DIAGNOSIS:
HEART FAILURE
HEPATOSPLENOMEGALY?
INVESTIGATIONS:
Blood investigations:
Hb 5.3
TLC 13900
Platelets 1.3
RBC count 1.52
Reticulocyte 0.5
Serum LDH 319
Serum total protein 13.7
Serum albumin 2.5
A:G-0.22
RBS 119.
CXR:
Chest x ray showed cardiothoracic ratio(CTR) more than 0.5. And money bag appearance indicating pericardial effusion.
Suddenly patient developed hypotension,and findings are
Raised jvp and Muffled heart sounds -BECK’S TRIAD.
2d echo showed RV diastolic collapse .
Diagnosis -cardiac tamponade.
Immediately Pericardiocentesis was done and 300ml fluid was drawn.
An reduced albumin to globulin ratio with increased protein would suggest increase in globulins.To identify the nature of globulin electrophoresis was done and GAMMA SPIKE is observed, which was monoclonal -M SPIKE.
Radio graphic images: osteolytic lesions present.
DIAGNOSIS : multiple myeloma.
TREATMENT:
Inj Bortezomib 2mg Sc /od
Inj Cyclophosphamide 400 mg in 500 ml NS Iv /od
These chemotherapeutic agents were given once every 15 -20 days
MAINTANENCE THERAPY:Tab . Dexamethasone 8 mg /odTab Septran Ds /BDTab Pan 40 mg od
CONTINUED MEDICATION FOR 6 months.Pericardial effusion was resolved after 6 months.Then she was put on chemotherapy once 15 days.Inj Bortezomib 2mg Sc /od
Inj Cyclophosphamide 400 mg in 500 ml NS Iv /od.
Inj Bortezomib 2mg Sc /od
Inj Cyclophosphamide 400 mg in 500 ml NS Iv /od.
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