Management of common medical emergencies in myeloma patients

Management of common medical emergencies in myeloma patients

Hyperviscosity

• may be seen in patients with high serum paraproteins levels (especially those of IgA and IgG3 type)
• patients have blurred vision, headaches, mucosal bleeding and dyspnoea due to heart failure
• in symptomatic patients
  • treat with therapeutic plasma exchange with saline fluid replacement
  • if plasmapheresis is not immediately available consider isovolaemic venesection with saline replacement as a holding measure
  • if transfusion is essential, exchange transfusion should be performed
• effective treatment for myeloma should be started promptly (1)

Hypercalcaemia

• up to 30% of patients may present with hypercalcaemia, majority in the context of active disease
• acute hypercalcaemia may present with CNS dysfunction (confusion, coma and obtundation), muscle weakness, pancreatitis, constipation, thirst, polyuria, shortening of the Q-T interval on ECG and acute renal insufficiency
• other causes such as hyperparathyroidism should be considered as well in these patients
• treatment of hypercalcaemia should be initiated as soon as possible (to minimise long term renal damage) along with the treatment of underlying disease o in mild hypercalcaemia (corrected calcium 2.6-2.9 mmol/l) re-hydrate with oral and /or iv fluids
  • in moderate-severe hypercalcaemia (corrected calcium >2.9 mmol/l) re-hydrate with intravenous fluids and give furosemide if required
  • all patients with moderate-severe hypercalcaemia should receive a bisphosphonate (1)

Cord compression

• is a medical emergency which requires rapid diagnosis and treatment
• seen in 5% of the patients
• clinical features varies but commonly include sensory loss, paraesthesiae, limb weakness, walking difficulty and sphincter disturbance
• MRI should be obtained immediately and neurosurgical or spinal surgical / clinical oncology consultation obtained
• treatment methods include
  • for non-bony lesions - local radiotherapy is the treatment of choice, should be started as soon as possible (preferably within 24 hours of the diagnosis)
  • for bony compression and/or to stabilize the spine - surgery is carried out for emergency decompression
• effective systemic therapy should be started promptly (1)

Early infection

• there is an increased incidence of early infection in myeloma patients associated with deficits in both humoral and cellular immunity
• around 10% of patients die of infective causes within 60 days of diagnosis
• neutropenia is not usually associated with early infection
• management of early infections include:
  • any febrile myeloma patient should be treated promptly with broad-spectrum antibiotics. Intravenous antibiotics are required for severe systemic infection or neutropenic sepsis
  • Aminoglycosides should be avoided, if possible
  • there is insufficient evidence to recommend the routine use of prophylactic antibiotics (1)

Reference:

• 1. Bird JM et al. Guidelines for the diagnosis and management of multiple myeloma 2011. Br J Haematol. 2011;154(1):32-75.