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CASE 5. 56 yr-old man HIV + 1997 Asymptomatic CD4 840 HIV viral load <40 ABC/3TC/ Efavirenz. CASE 5. Sudden onset of severe, sharp lancinating mid thoracic back pain MRI reveals T8/L5 compression fracture Bone scan negative for lesions

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case 5
CASE 5
  • 56 yr-old man
  • HIV + 1997
  • Asymptomatic
  • CD4 840 HIV viral load <40
  • ABC/3TC/Efavirenz
case 51
CASE 5
  • Sudden onset of severe, sharp lancinating mid thoracic back pain
  • MRI reveals T8/L5 compression fracture
  • Bone scan negative for lesions
  • Dexa scan reveals spinal osteoporosis…T score -3.4
case 52
CASE 5
  • Hb decreased from 145 to 110 (normocytic) over last 6 months without obvious cause
  • Creatinine increased from 70 to 176 micromole/l
case 53
CASE 5
  • Anemia workup for all usual causes negative
  • u/s kidneys…normal sized kidneys…no obstruction
  • u/a…non active sediment
  • alb/creatinine…14 (<2 normal)
  • Prot/creatinine….0.150g/l (ULN)
case 54
CASE 5

What would you do?

case 55
CASE 5
  • Skeletal survey…14mm punched out lytic lesion in skull
  • Urine immunoelectrophoresis reveals 8.4 gm protein/24 hrs with free monoclonal kappa light chain proteins (bence jones) accounting for 50% of protein with reminder being glomerular in nature
case 56
CASE 5
  • Confirmatory bone marrow biopsy reveals 80% monoclonal plasma cells
case 57
CASE 5
  • Will receive radiotherapy to spinal compression fractures
  • Will undergo chemotherapy followed by autologous stem cell transplant
  • Bisphosphonate therapy