A 42-Year-Old Man With Backache and Fatigue After a Divorce

A 42-Year-Old Man With Backache and Fatigue After a Divorce

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Ankit Raiyani, MBBS, MD, DNB (Hematology); Vikramjit Kanwar, MBBS, MBA, MRCP(UK)

July 09, 2020

Editor’s Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

A 42-year-old businessman describes fatigue over the past 6 months, after a divorce. He also reports intermittent low back pain, which has been relieved by over-the-counter ibuprofen. He reports that he has otherwise been in generally good health and attributed his symptoms to depression, for which he has been seeing a therapist.

He takes over-the-counter vitamin supplements but no prescription medications, including antidepressants. His travel history is significant only for a trip to the Bahamas with his new girlfriend 1 month ago. He explains that since his trip, his backache worsened. It is now waking him up at night. Sometimes, when he wakes, he feels feverish and sweaty. He reports that he has also lost a “few pounds” of weight. Concerned by these symptoms, his girlfriend persuaded him to consult a physician.

The patient’s pain is confined to his lower back and is not relieved by heat or by rest. He does not have any other bone aches or pains or any joint pain or swelling. He has no significant history of rashes or bruising. He does not describe a cough, wheeze, chest pain, hoarseness, shortness of breath, or other respiratory symptoms. The patient quit smoking 4 years ago after an episode of severe pneumonia. He consumes alcohol in moderation and denies using recreational drugs.

Medscape © 2020 WebMD, LLC

Any views expressed above are the author’s own and do not necessarily reflect the views of WebMD or Medscape.

Cite this: Ankit Raiyani, Vikramjit Kanwar. A 42-Year-Old Man With Backache and Fatigue After a Divorce – Medscape – Jul 09, 2020.

Consultant, Qure Hematology-Oncology Group, Ahmedabad, Gujarat, India

Disclosure: Ankit Raiyani, MBBS, MD, DNB (Hematology), has disclosed no relevant financial relationships.

Director, Qure Hematology-Oncology Group, Ahmedabad, Gujarat, India; Adjunct Professor, Albany Medical College, Albany, New York

Disclosure: Vikramjit Kanwar, MBBS, MBA, MRCP(UK), has disclosed no relevant financial relationships.

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A 42-Year-Old Man With Backache and Fatigue After a Divorce

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What Is Multiple Myeloma?

What Is Multiple Myeloma?

Multiple myeloma is a type of blood cancer. It starts in your bone marrow, the spongy tissue inside bones. This is where your body makes blood cells, including a certain type called plasma cells. These cells can grow out of control and crowd out the normal, healthy ones in your bone marrow. When they build up, they form a tumor. The name “multiple myeloma” means there is more than one tumor.

Scientists aren’t sure what causes multiple myeloma. It might be linked to changes in DNA. But they do know that some people have a higher chance of getting the disease than others. Things that make your risk go up include:


In the early stages of multiple myeloma, you might not have any symptoms, or they might be very mild. Everyone who has the disease will feel different effects. In general, symptoms of multiple myeloma include:

Multiple myeloma can affect your body in different ways.

Bones: The disease can make your bones weak and easy to break.

Blood: Because your bone marrow makes blood, multiple myeloma can affect how many healthy blood cells you have.

Multiple myeloma can lead to too much calcium in your blood. This can give you belly pain and make you:

Multiple myeloma and high levels of calcium can hurt your kidneys and make it harder for them to filter your blood. Your body might not be able to get rid of extra salt, fluid, and waste. This can make you:

To diagnose multiple myeloma, your doctor will do a combination of tests.

Blood tests

Urine tests

Bone and bone marrow tests

Karyotyping and fluorescence in situ hybridization (FISH)

When your doctor diagnoses multiple myeloma, she’ll try to give you an idea of how much the cancer has grown or spread in your body. This is called the stage of your disease.

Doctors can tell what stage the multiple myeloma is in by looking at X-rays of your bones and testing your blood, pee, and bone marrow.

Your stage might be:

Standard treatments for multiple myeloma include:

Immunomodulatory drugs: These drugs are the workhorses of multiple myeloma treatment. They work on your immune system. Some turn on certain immune cells, and others stop the signals that tell cancer cells to grow so they kill myeloma cells.

Proteasome inhibitors: Proteasomes are protein complexes that help cells — including cancer cells — get rid of old proteins so they can be replaced by newer versions. Proteasome inhibitors prevent cancer cells from doing this. As old proteins pile up, the cancer cells die.

These drugs are used at all stages of the disease. High doses can kill multiple myeloma cells. They’re also used to ease symptoms like pain and pressure by stopping white blood cells from racing to affected areas. And they can help with side effects of chemotherapy, like nausea and vomiting.

HDAC inhibitors: These drugs stop multiple myeloma cells from making too much of the histone deacetylase (HDAC) protein, which helps malignant cells quickly grow and divide.

Antibodies: These immunotherapy drugs help your immune system fight cancer. They bring antibodies into your body to target specific proteins on multiple myeloma cells.

These drugs treat cancer by killing cells that are in the process of dividing. They also kill healthy cells around them, which causes unpleasant side effects.

Stem cell transplants: There are two types of stem cell transplant for multiple myeloma:

You usually get the transplant along with chemotherapy.

This treatment uses high-energy particles, or rays, to damage cancer cells and prevent them from growing. You get it from a machine that sends high-energy rays into your body.

Adjunctive care: These treatments help manage the side effects of medications and complications of multiple myeloma.

Supportive care: These treatments can make life with multiple myeloma easier. They include physical therapy, nutritional counseling, massage, exercise, and more.

Hospice care:
When your condition no longer responds to medication, this option will provide pain and symptom management to keep you as comfortable as possible.


The Multiple Myeloma Research Foundation: “Learn the Basics About Multiple Myeloma,” “Risk Factors for Multiple Myeloma,” “Multiple Myeloma Symptoms,” “Multiple Myeloma Tests,” “Diagnosis,” “Standard Treatments,” “Stem Cell Transplants,” “Supportive care.”

American Red Cross: “Plasma.”

Johns Hopkins Medicine: “Multiple Myeloma.”

The American Cancer Society: “Do We Know What Causes Multiple Myeloma?” “What Are the Risk Factors for Multiple Myeloma?” “Signs and Symptoms of Multiple Myeloma,” “Staging Multiple Myeloma,” “Diagnosing Multiple Myeloma from Test Results,” “How Is Multiple Myeloma Staged?”


What you need to know.

How they work for blood cancers.

Separate fact from fiction.

And how to best treat them.


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What Is Multiple Myeloma?

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