132 - GP Letter

Thank you for your referral of John, whom I reviewed for suspected Multiple Myeloma. The patient presented with fatigue, bone pain, and recurrent infections, prompting this review. The patient's overall well-being has been significantly impacted by these symptoms. On examination, no lymphadenopathy or hepatosplenomegaly was noted. The patient was alert and oriented. **Past Medical History:** - Hypertension - Osteoporosis - Recurrent chest infections **Medications:** - Amlodipine 5mg daily - Alendronic acid 70mg weekly - Co-amoxiclav 625mg twice daily (for current infection) **Investigations:** **SA Path 1 November 2024:** Hb 105 g/L WCC 4.5 x10^9/L LC 1.2 x10^9/L PLT 250 x10^9/L Biochem NAD Igs all Abnormal PP 0 SFLC Abnormal EBV and CMV not detected Hep B, Hep C and HIV not detected **Clinpath 1 November 2024:** Hb 105 g/L MCV 85 fL WCC 4.5 x10^9/L LC 1.2 x10^9/L PLT 250 x10^9/L Biochem NAD Igs all Abnormal B12 Normal Iron studies Normal Urine culture Negative ESR 60 mm/hr CRP 20 mg/L HbA1c 5.5% TFTs Normal Lipid profile Normal PSA 0.8 ng/mL **Clinpath 1 November 2024:** Hb 105 g/L WCC 4.5 x10^9/L LC 1.2 x10^9/L PLT 250 x10^9/L Biochem NAD **Impression:** - Suspected Multiple Myeloma, currently under investigation. - Hypertension, Osteoporosis, Recurrent chest infections. The patient's condition is concerning due to the elevated serum free light chains and abnormal immunoglobulin levels. The blood counts are stable, but the ESR is elevated, indicating ongoing inflammation. Imaging results are pending. The risks of progression include worsening bone disease, renal impairment, and increased susceptibility to infections. **Suggested Management Plan:** - Repeat serum free light chains, protein electrophoresis, complete blood picture, renal function, electrolytes, liver function testing, IgG, IgM, IgA in 3 months. - Annual physical reviews, including assessment for specific clinical signs such as lymphadenopathy, hepatosplenomegaly, and evaluation for infections including specific immune markers. - Counselling points for annual reviews, such as staying up to date with non-live vaccinations and age-appropriate malignancy screens. **An earlier review should be arranged if:** - Constitutional symptoms, new lymphadenopathy or hepatosplenomegaly, CRAB criteria, or rapidly rising K/L ratio. - Hypogammaglobulinaemia with frequent infections and potential eligibility for specific treatments. The patient will be followed up in the haematology clinic in 3 months. The referring clinician should be aware of the potential for disease progression and should contact the haematology team immediately if any concerning symptoms arise.