3 Week History Of Back Pain-Virtual Morning Report From The Clinical Problem Solvers-#570 With Additional Resources On Plasma Cell Disorders

Posted on February 5, 2022 by Tom Wade MD

Here is the home page of The Clinical Problem Solvers.

Here is the link to the home page for Virtual Morning Report [From this link you can directly access all 572 episodes].

Here is the Clinical Problem Solvers page with the list of links to all the Diagnostic Schema.

Here is the Clinical Problem Solvers page with the list of links to all the illness Scripts.

Episode 570 – Virtual Morning Report – January 27 – Back Pain [watch on the Clinical Problem Solvers website].

Case presenter – Alec Rezigh

Case overview & teaching points – Here

“Solitary plasmacytoma-No CRAB symptoms (Hypercalcemia, Renal Failure, Anemia, Bone Disease)*

Final Diagnosis: plasmacytoma. See also Multiple Myeloma Diagnostic Criteria. Both are from emedicine.medscape.com

Diagnostic Schema:

Bone lesions

Illness Script:

Multiple Myeloma

Illness Script:

Paraproteinemia

Illness Script:

Waldenström’s Macroglobulinemia

Diagnostic Schema:

IgM Disorders

 

In this post I link to and excerpt from The YouTube Clinical Problem Solvers‘ “January 27, 2022 “30-minute Thursday” VMR – back pain” [Link is to the video on YouTube]

By watching the video on YouTube, you can follow along in the transcript.

The case is of a 70-year-old patient with a 3-week history of low back pain who over the last week has to use a walker to ambulate.

All that follows is from the above outstanding resource:

The teacher states in the transcript that the emergency department physician ordered CT of abdomen and pelvis for renal colic. It is more likely that ed physician ordered them looking for abdominal, pelvic, or retroperitoneal disease causing referred back pain as the U/A was completely normal.

In all back pain patients, the question is always: Is imaging indicated (whether back pain is acute, subacute, chronic, or acute on chronic).

And if imaging is indicated, what imaging studies are needed?

From the transcript:

9:09 Two red flags of the need for imaging are overt neurologic compromise or a history of cancer.

09:18
negative predictive value of an esr and
09:21
crp
09:22
in low to medium risk back pain is very
09:25
high so what would i do in real life for
09:27
this patient if his esr and crp are low
09:29
i would not image him and i would wait
09:31
to see how the disease progresses
09:33
everything that i am worried about and
09:35
that the chat has mentioned ranging from
09:36
infections to malignancies is associated
09:39
with at least minimal elevation of those
09:41
inflammatory markers
09:42
so that’s number step number one
09:45
step number two
09:47
if a patient has a metastatic infection
09:50
in their back
09:52
you’ll find it in one of two other
09:55
places almost all the time
09:57
the first is if they have hematogenous
09:59
dissemination of pyogenic organisms like
10:02
staph and strep you’ll find it in the
10:03
blood so blood cultures are very
10:05
important
10:07
that presentation is less consistent
10:09
with three weeks of progressive back
10:10
pain and would be more acute what is
10:12
more likely here if this is infection is
10:14
this person has a granulomatous
10:16
infection
10:17
like tuberculosis brucella
10:19
and um and others
10:22
now where do those infections come from
10:24
they almost always come from the lungs.

 

10:26
the source
10:27
of these infections that are granulomas
10:30
and go to the spine is often pulmonary
10:32
so this is the time to order not only
10:35
esr crp and basic lab but to consider
10:38
ordering a chest x-ray in a patient with
10:40
no pulmonary symptoms
10:42
and if he has anything on x-ray
10:44
the chances of something bad in his back
10:46
goes through the roof
10:56: All the labs were normal except the platelet count of 455. ESR and CRP were normal.
11:31
in regards to imaging had a
11:33
x-ray of the lumbar spine
11:36
which showed
11:37
mild multi-level spondylus but no clear
11:40
fractures or other abnormalities
11:42
and then did have a chest x-ray
11:45
which showed some bilateral very small
11:48
pulmonary nodules and some mild
11:50
emphysema
11:52
didn’t have any to compare to previously
12:14 [The ed got]  
 a ct abdomen and pelvis
12:17
which didn’t show any
12:19
gu pathology [again I think the ED got the CT looking for referred pain} but did show a two by three
12:22
by five centimeter
12:25
expansion destructive mass in the sacrum
12:29
that replaced most of the vertebral body
12:31
and eroded through the disc space
12:35
and
12:36
produced some narrowing of the epidural
12:38
space but no clear spinal cord
12:40
compression
12:42
and this was confirmed on mri
12:47
and was hyper intense
12:50
on
12:50
on imaging with t1 t2
13:15
thrombocytosis or an elevated platelet
13:17
count is pretty robust evidence of
13:18
inflammation so as soon as you get that
13:20
data back you got to go all the way with
13:22
imaging, it’s very very unusual to have
13:24
thrombocytosis that is otherwise
13:27
unexplained so in real life once you get
13:29
that platelet count you know you need to
13:30
get imaging of some way shape or form
13:34
so here’s the what i told you might come
13:35
up which is how do you decide between ct
13:37
and mri i’ll tell you that it’s not
13:39
uncommon as in this case that both are
13:41
obtained but but if your patient doesn’t
13:43
have overt neurological compromise you
13:46
should get a ct why because it’s much
13:48
faster and covers much more than just
13:51
the cord the advantage of mri is it sees
13:54
the cord way better but the ct seizes
13:56
the bones better actually way better
13:57
than mri and sees the less rest of the
14:00
abdomen
14:01
so unless you are worried specifically
14:02
about neurological compromise i.e the
14:04
chord is involved you should get an mri
14:05
otherwise ct is faster and more more
14:07
extensive so here the order in which
14:09
things were obtained makes a lot of
14:10
sense
16:45
um and i think you know the most common
16:47
scenario is when we see a bone lesion we
16:49
see something else so here’s the common
16:51
scenarios you have mass in the liver and
16:52
a bone lesion or you have a renal cell
16:54
and you have a bone lesion and so the
16:56
question i think in this case is what
16:57
happens to the probability of malignancy
17:00
and what kind of malignancies only show
17:01
up as an isolated bone lesion without
17:03
disease anywhere else
17:05
and that’s tricky because there are some
17:07
cancers that will just show up in the
17:09
bone and will show up nowhere else like
17:11
melanoma for example or multiple myeloma
17:15
and so
17:16
if you just know bone lesion it’s
17:18
probably cancer 10 times more than
17:20
infection but if you say
17:22
isolated bone lesion without evidence of
17:25

cancer anywhere else

17:27
then it starts to narrow a little bit
22:41
but why is it not oh why if you’re an if
22:44
you’re a learner who’s who who isn’t
22:46
fully dived into the world of aspeb why
22:47
isn’t the answer obviously multiple
22:48
myeloma when you say you have a bone
22:50
lesion and a positive aspect and the
22:52
answer is that at the age of above 50
22:56
you have a one percent chance of having
22:57
an incidental monoclonal protein since
23:00
you because of your age and that risk
23:03
goes up with every decade so he has
23:05
about a four or five percent chance of
23:06
having a monoclonal spike just by being
23:09
alive independent of this tumor
23:12
what else do you make of the possibility
23:14
that he has no criteria of systemic
23:17
effects of myeloma he has no
23:18
hypercalcemia no renal insufficiency no
23:20
anemia right and so that’s where i think
23:23
sami’s thought in the chat is really
23:25
important which is does he have not so
23:27
much a multiple myeloma but a version of
23:30
multiple myeloma that’s restrictive
23:32
called a plasmacytoma
23:34
now just be clear plasmacytoma is just a
23:36
collection
23:38
of abnormal plasma cells that doesn’t
23:41
meet criteria for multiple myeloma
23:43
because it’s there’s no crab criteria
23:46
and there’s less than 10 plasma cells
23:49
and most plasmacytomas occur along with
23:51
multiple myeloma where there’s just a
23:53
focal collection of plasma cells that
23:55
you can see radiographically but
23:57
sometimes they can be solitary
23:59
and in solitary it’s usually exactly
24:01
where this patient has their
24:02
plasmacytoma and here’s the problem
24:04
seventy percent of them go on to develop
24:06
multiple myeloma
24:08
so i think with the step is a lead to
24:10
say it might be true true and unrelated
24:12
and this person may turn out to have
24:14
osteosarcoma or they may actually turn
24:16
out to have a cryptic infection that
24:17
presented atypically and left the lung
24:19
so quickly before it left a signature
24:21
but with the s pep it’s hard not to
24:23
worry about multiple myeloma or more
24:25
likely because of the absence of lytic
24:27
lesions elsewhere and the absence of
24:28
crab criteria that you might have a
24:30
solitary plasmacytoma of the bone
24:33
which
24:34
practically speaking is no different
24:36
than multiple myeloma because within
24:37
three years he has a 70 chance of
24:39
getting it but i love alec
24:42
your evaluation is very practical here
24:45
it doesn’t matter if you’ve got tb or
24:46
brazil the truth is like when there’s a
24:48
problem that is kind enough to declare
24:50
itself by showing up in one specific
24:52
area just look at it it’ll tell you it
24:54
won’t hide there are very few things of
24:56
biopsy negative diseases in medicine or
24:58
very few and so given that we’re out of
25:00
time i’m hopeful that this biopsy is
25:02
very positive which i i know you alluded
25:04
to so i’ll pass them like to you
25:06
before that i just want to say i
25:09
completely didn’t think about a
25:11
plasmacytoma so sammy rg thank you for
25:15
reminding me that was fantastic
25:20
a great discussion um and uh you guys
25:22
are right on the money it was the blast
25:24
it came back it was very consistent with
25:25
the solitary plasmacytoma
25:27
so well done sammy and and charming and
25:30
nrg one
25:32
so
25:33
you know
25:34
hematology became involved after that
25:36
and uh fortunately his disease was very
25:38
isolated just to that lesion so he got
25:41
some physical therapy and ended up
25:43
getting radiation and he’s doing much
25:45
much better now
25:46
and uh there’s gonna pardon me monitor
25:49
him serially and determine you know if
25:51
he needs any additional therapies in the
25:52
future but um
25:54
thanks for letting me present and um i
25:56
always learn a lot when i’m here so uh
25:58
awesome
26:01
alec
26:02
funny i always also learn a lot when
26:05
you’re here coincidence
26:07
i i don’t think so um thank you all so
26:10
so much this was an amazing case i was
26:13
yeah i
26:14
completely didn’t think about
26:15
plasmocytomas at all it’s been a while
26:17
so i know my reading for today um sammy
26:21
great job rafa
26:23
jack thanks so much for presenting and
26:25
rafa for being teaching points and rj
26:28
always a pleasure any um any reflections
26:30
already before we pass it to our rafa
26:33
for
26:35
well i really just want to shed light on
26:37
uh you know what alec is doing alec is
26:39
it is
26:40
diving into the field of clinical
26:42
reasoning and as a junior faculty member
26:44
you should know and remember his name
26:46
anytime clinical reasoning comes up um
26:48
alex you’re doing absolutely tremendous
26:49
work i think it’s so um awesome to see
26:52
you here joining us on bmr alex is
26:53
getting his cases out there published
26:55
left right and center and my hope and
26:57
dreams are that we get alec to be a
26:59
discussant um on one of either a written
27:01
case or here at vmware soon so
27:03
a
27:04
yeah i just want to put a plug for those
27:06
of you listening on youtube and those of
27:08
you live that before you is a um
27:11
evolving expert and future legend in
27:13
clinical reasoning and you may not
27:15
appreciate that um
27:17
but we we certainly do we’ve known alex
27:19
since he was a r2 right are two or three
27:21
i forget archery r3 yeah final year
27:24
residency so it’s a treat to see you
27:26
like climbing up the ladder and i think
27:28
honestly
27:29
um your your persona and um your
27:32
relentless work in clinical reasoning
27:34
will only lead to one destination so
27:36
it’s great to see it happen
27:38
thank you all and i’ll pass the mic to
27:40
rafa to take us home the other are
27:43
so many hours
27:45
so thank you all uh incredible case and
27:47
discussion everybody uh congratulations
27:50
so we have this patient with back pain
27:52
and regular managed to think about
27:54
primary versus secondary causes also
27:56
when it comes to age for example you
27:58
don’t expect like a younger male patient
28:00
to have chronic back pain so age for
28:02
example is important here because it
28:04
could be dealing with and closing
28:05
spondylitis for example tempo is very
28:08
important as well so we don’t expect
28:09
like chronic back pain in our elderly
28:11
patient and just be fine with that the
28:13
most common cause is muscular muscular
28:14
musculoskeletal arrangements but we have
28:17
to look for any red flags these include
28:20
things like pain at night fever chills
28:22
weight loss significant past medical
28:24
history um maybe you’re dealing with a
28:27
patient with a cancer or
28:28
immunosuppression are no response
28:30
purpose therapy or neurological deficits
28:33
and when it comes to back pain you can
28:34
divide in different buckets um i’d like
28:36
to think about spinal stenosis condole
28:38
arthropathy any metastasis for example
28:41
prostate cancer that we discussed about
28:42
today vertebral osteomyelitis
28:45
degenerative causes like osteoarthritis
28:47
ventriculopathy in the setting of disc
28:49
herniation and another thing that
28:51
charming reminders is to think about
28:52
primary bone malignancy as well when it
28:55
comes to the basic labs um rabby uh gave
28:57
us this braille that look at the spsr
29:00
crp if television considered imaging
29:02
these patients with x-ray or mri if not
29:05
consider watch and observe and then we
29:08
started this patient actually had
29:09
elevated the platelets and it’s probably
29:12
a secondary cause to the inflammation
29:14
process that’s going on uh primary cost
29:17
of thrombosis could be polystyrene
29:19
average but less likely because you
29:21
would expect to see like high hemoglobin
29:23
leukocytes as well and then when it
29:26
comes to bone lesions we thought about
29:28
infection and malignancy um this patient
29:30
was from el salvador so we thought about
29:32
tb and brazil under the spill that tb
29:35
usually
29:36
um leads to the upper spine involvement
29:39
for cell low spine involvement and when
29:41
it comes to malignancy for the barge we
29:43
usually divide that into three buckets
29:45
osteoblast collisions for example
29:47
prostate cancer oscillating collisions
29:49
for example nasal multiple myeloma and
29:51
melanoma and mixed lesions in the side
29:53
of chia and breast metastases and then
29:56
there is this barrel that i love
29:59
patients uh older than 50 years old
30:01
there’s a chance of increasing of
30:02
fighting a benign monoclonal spike and
30:05
actually this chance progresses as this
30:07
patient uh get older and then we saw
30:10
that this patient actually had of
30:11
solitary plasmocytoma which is basically
30:13
multiple myeloma less
30:15
a
30:17
the crab symptoms that we usually
30:19
associate with multiple myeloma like
30:21
hypercalcemia renal injury anemia and
30:24
also bone lesions but there’s this
30:27
chance of progressing to multiple
30:29
myeloma within the years so thank you
30:30
everyone such an educational case and i
30:32
hope to see everyone tomorrow
30:37
amazing rafa as always such a boss see
30:41
you all tomorrow can’t wait have a great
30:44
rest of your day wherever you are
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