A 70-year-old woman comes to the office due to back pain, fatigue, and inability to carry out her daily work. The pain began 6 months ago and has slowly intensified. The patient had a hip fracture 3 months ago but has no other medical conditions. She is a lifetime nonsmoker and drinks alcohol on social occasions. She currently takes no medications. The patient has no extremity weakness or paresthesia. She has mild constipation; urination is normal. Initial laboratory results are as follows: Dipstick urinalysis is normal. The patient is informed about the prognosis, potential risks, and benefits of therapy. She declines treatment. The physician documents their discussions and arranges for follow-up visits. One month later, the patient is brought to the emergency department by family members due to acute-onset blurry vision, headache, confusion, and epistaxis. A detailed history from the family members fails to identify any precipitating factor. On examination, the patient is lethargic but arousable. Scant gingival bleeding is noted. The lungs are clear to auscultation; there is no peripheral edema. Serum creatinine is 2.4 mg/dL. Which of the following is the most likely cause of this patient's acute change in status?

Question

A 70-year-old woman comes to the office due to back pain, fatigue, and inability to carry out her daily work.  The pain began 6 months ago and has slowly intensified.  The patient had a hip fracture 3 months ago but has no other medical conditions.  She is a lifetime nonsmoker and drinks alcohol on social occasions.  She currently takes no medications.  The patient has no extremity weakness or paresthesia.  She has mild constipation; urination is normal.  Initial laboratory results are as follows:  Dipstick urinalysis is normal. The patient is informed about the prognosis, potential risks, and benefits of therapy.  She declines treatment.  The physician documents their discussions and arranges for follow-up visits.  One month later, the patient is brought to the emergency department by family members due to acute-onset blurry vision, headache, confusion, and epistaxis.  A detailed history from the family members fails to identify any precipitating factor.  On examination, the patient is lethargic but arousable.  Scant gingival bleeding is noted.  The lungs are clear to auscultation; there is no peripheral edema.  Serum creatinine is 2.4 mg/dL.  Which of the following is the most likely cause of this patient's acute change in status?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf6a_f1c1_8f63_09bab8cfff4e_MD0005_00 This patient likely has hyperviscosity syndrome, which typically arises in the setting of excessive production of monoclonal IgM. Although most common in patients with Waldenström macroglobulinemia, a minority (~0.5%) of patients with multiple myeloma (MM) generate monoclonal IgM and are at risk for the condition. Symptoms arise when IgM clogs the microcirculation in the brain, leading to headache, dizziness, vertigo, nystagmus, hearing loss, and vision impairment. Severe cases can present with somnolence, coma, or seizures. Mucosal hemorrhage (eg, nasal or oral bleeding) can occur due to impaired platelet function. Treatment with plasmapheresis alleviates symptoms. Other complications of MM include hypercalcemia, renal insufficiency, infections (eg, pneumonia, urinary tract infection), thrombosis (arterial and venous), and skeletal lytic lesions. (Choice A) Renal failure can occur acutely or gradually due to light-chain cast nephropathy or deposition disease. Patients can develop dyspnea, nausea, peripheral edema, mental status changes, and eventual anemia due to kidney damage. However, renal failure does not typically cause blurry vision. In addition, this patient has no peripheral edema and the creatinine level is only moderately elevated, making acute kidney injury less likely as the sole explanation for her symptoms. (Choice B) Patients with fulminant hepatic failure may develop acute mental status changes due to hyperammonemia and bleeding due to platelet dysfunction. However, MM is not commonly associated with liver complications. In addition, this patient has no history of liver disease that would predispose her to fulminant hepatic failure. (Choice C) Acute disseminated intravascular coagulation (DIC) can present with bleeding (eg, petechiae, ecchymosis), acute renal failure, and hepatic dysfunction (eg, jaundice). However, blurry vision would be atypical. In addition, although acute DIC can be seen in leukemia (eg, promyelocytic leukemia), it is uncommon in MM. (Choice D) Hypercalcemia can be asymptomatic or cause anorexia, nausea, polyuria, constipation, weakness, and confusion. However, hypercalcemia is not associated with mucosal bleeding or blurry vision. Educational objective: Although hyperviscosity syndrome is more common in Waldenström macroglobulinemia, it can also occur in patients with multiple myeloma who have elevated levels of monoclonal IgM. Typical findings include headache, dizziness, vertigo, nystagmus, hearing loss, and vision impairment. References: Hyperviscosity syndrome in plasma cell dyscrasias. (http://www.ncbi.nlm.nih.gov/pubmed/14631546)

A 70-Year-Old Woman Comes to the Office Due to Back