Multiple myeloma with lower back and leg pain as the first symptom

Multiple myeloma (MM) is a kind of plasma cell malignant proliferation disease, belongs to theblooddiagnosis and treatment category, accounting for 10% of thebloodsystem tumor, lesions often affect the ribs, thoracic spine, lumbar spine, pelvis and other bonesMM patients often visit orthopaedics or pain due to pain in the corresponding boneIf the lesions affect the lumbar spine, often appear lumbar and leg pain, often need to be identified with lumbar disc protrusion,osteoporosis, lumbar hip soft tissue injury and rheumatism diseases, such asdiagnosisDue to the complexity of theclinicalof multiple myeloma, it is easy to be confused with these diseases, and may be misdiagnosed or misdiagnosedData show that the misdiagnosis rate of MM is as high as 54.00% to 69.11%This paper will review two cases of multiple myeloma with back and leg pain as the first symptom, and discuss, hoping to helpclinicians to improve awareness of the disease, reduce misdiagnosis, mistreatment1Case informationCase 1: Patient, male, 71 years old, admitted to hospital for "back pain june"The patient had no cause before June to develop lower back pain discomfort, no fever, no symptoms of lower limb pain, the initial pain symptoms of the disease is light, not paid attention toPrior to April, pain symptoms worsened, visual simulation score (visualue scale, VAS analog) score: 2 to 4 points, the patient's own oral ibuprofen analgesia, pain no reliefBefore February in my hospital outpatient CT examination show: lumbar degenerative change, lumbar 3 vertebrae mild compression changesBone density check: lumbar t-value: -2.8To "rely on the kaxio tablets 60mg, oral, 1 time / day", "ostrichol capsule 0.25 sg and calcium carbonate tablets 1 tablet, oral, 2 times / day" treatment In February, the effect is not good, VAS: 4 points, then admitted to the hospitalphysical examination: no rash on the lower back, L1-5 vertebral ratchet tenderness , double lower leg straight leg elevation test (-)Post-admission related examination: review bone density: lumbar T value: -2.9; blood routine: 102g/L; blood clotting, liver and kidney function normal; sugar antigen, CEA, PSA and AFP and other tumor indicators normalStill consider osteoporosis, to "the acid injection 5 mg, static drops once" and "aminol oxycodone tablets 0.5 tablets, oral, 3 times / day" treatment after 1 week, the pain symptoms not only no relief but aggravated, VAS: 6 pointsFurther lumbar mrI flat sweep examination: lumbar vertebrae multiple spot flareshadowconsider the possibility of myeloma, further examination:immunefixed electrophoretic M protein ( , serum and urine , argon light chain ) , urine protein (-), 24h urine protein total 7.24g, asked a haemome doctor consultation after bone marrow puncture: plasma cells accounted for 60.3%, is an isomorphic celldiagnosis multiple myeloma and transferred to a haematology department for further treatment case 2: The patient, female, 62 years old, was admitted to hospital for "lower back and lower limb pain in March, aggravated by January" The patient suddenly developed lower back and right lower limb pain after the weight gain in March, and the pain gradually eased after resting at home and taking sodium dichlorofenate After exertion before January, the pain in the lower back and right lower limbs is aggravated again, with mild pain in the left lower limb, which is aggravated during activity Lumbar CT examination: L4-5 intervertebral disc slightly protruding; Local hospital according to the "lumbar disc protrusion" to hormone and glycol anti-inflammatory dehydration treatment, pain no obvious relief, then to my hospital, i clinic to "lumbar disc protrusion" admitted to the hospital physical examination: L3, L4, L5 vertebrae ratchet tenderness (-), right lower limb straight leg lift test 80 degrees, left lower limb straight leg elevation test (-) After admission to the lumbar vertebrae MRI show: L4-5 intervertebral disc mild lysing to the right L4-5 right side occlusion, pain is not eased Into a walklum tintolum spine enhancement MRI show: lumbar vertebral body see scattered in the uneven reinforcement of the stove Systemic bone ECT showed: ribs, thoracic spine, lumbar vertebrae, pelvis and right femur polysacchae Considering the possibility of multiple myeloma, further examination is carried out: immunity fixed electrophoretic M protein, argon (plus), serum, slug light chain (-), urine light chain (plus), bone marrow puncture: pulp cells accounted for 48.7%, is an isomorphic cell Diagnosed with multiple myeloma and transferred to a haematology department for further treatment 2 Discussion of most MM at the beginning of the onset of multiple bone pain throughout the body, with lower crotch pain is the most common Li Shoujing and others on 1240 cases of MM initial symptoms of the study showed that bone pain as the first performance of about 55.2% Li Minyan and other 124 initial visitmm patients clinical characteristics analysis found that 69.4% of patients to bone pain mainly admitted to hospital, including the lower tibia is the most common, about 38.7%, the rest of the performance of chest and back and double rib pain, lower limb pain, left hip bone pain, neck pain, right shoulder pain, bone joint pain Pain Department as a new department, in the daily of the of diagnosis and treatment of lower and leg pain patients more Because of mm disease hidden, clinical manifestations are diverse, to lumbar bone pain as the main clinical manifestations of MM patients are often easy to be confused with common pain diseases, such as lumbar disc protrusion, osteoporosis, and even rheumatic diseases, resulting in misdiagnosis or missed diagnosis for example, osteoporosis is often characterized by bone pain in some where or multiple parts of the body, and antiosteoporos treatment is often effective In addition, Li Zhaoyuan and other observations of the results of the treatment of MM-induced bone pain by the acid icing acid found that the oxalic acid can effectively reduce the bone pain caused by MM Therefore, when MM patients with bone pain as the main clinical manifestation combined osteoporosis, such as giving oxalate acid anti-osteoporosis treatment can reduce pain, it is more likely to cause missed diagnosis patients in case 1 combined with osteoporosis, and after treatment of pyrethic acid did not provide good pain relief, so as not to cause missed diagnosis MM one is the abnormal proliferation of plasma cells monoclonal B-cell malignancy disease, due to the excessive proliferation of plasma cells to produce monoclonal immunoglobulin (M protein) and / or light chain protein, and invasion of adjacent bones, resulting in bone damage, and cause bone pain, but also often cause anemia, renal insufficiency, hypercalcemia, infection fever, blood clotting abnormality Patients with lumbar and leg pain are mainly x-rayed and CT-tested when treating pain, and an MRI flat-sweep examination may be used when considering the presence of lumbar disc protrusion Zhang Yan and other clinical performance studies of Multiple myeloma X-ray, CT and MRI show that the sensitivity of X-ray diagnosis MM is 65.3%, the diagnostic accuracy rate is 68.1%, the sensitivity of CT diagnosis is 98.6%, the correct rate is 87.3%, the correct rate is 97.6%, the correct rate is highly higher than X-ray, and MRI is obviously 100% mm detection Yu Hongmei and other studies showed that X-ray, CT and MRI detection rates were 47.7%, 82.9% and 93.2%, respectively, and the results of another group were similar, with the positive rate of CT test being only 75% and MRI test ingon svity at 92.3% Of the two cases reported in this time, one of the cases was not diagnosed with MM using MRI flat sweep, and the lesions were detected after the use of enhanced MRI tests Therefore, MRI enhancement tests may be considered when MRI flat sweeps are not found to be significantly related lesions Whole body bone imaging (ECT) can detect the metabolism of whole body bones at once, more than other imaging tests can detect destructive lesions, for patients with multiple bone pain or X-ray, CT and MRI negative, ECT examination can be used, may be more early to find other imaging tests can not detect bone damage, especially the presence of systemic bone pain patients, can be more efficient detection of lesions MM is divided into symptomatic myeloma (active myeloma) and asymptomatic myeloma (smoke-type myeloma) mm patients who are the first to be diagnosed in the pain department are active myeloma, according to the 2015 China Multiple myeloma diagnosis guidelines, the diagnostic criteria must include: (1) myeloceutic plasma cell ratio of 10% and/or tissue biopsy to prove the presence of plasma cell tumor; Therefore, when active myeloma is highly suspected, the detection of M protein in blood and urine becomes an efficient and inexpensive, small-damage dissonance test When positive results of M protein in blood or urine are found, bone marrow puncture examination can be further carried out to identify the lesions, combined with the patient's relevant clinical manifestations and other blood and/or imaging test results can be confirmed MM in general, the possibility of misdiagnosis, misdiagnosis, or the integration of other diseases should be considered for disease diagnosis that does not fully explain symptoms and treatment options that do not effectively control pain symptoms Patients with bone pain should be highly alert to the possibility of MM while diagnosing or ruling out other related diseases