This is a case of a 69 year-old female who was flown in from the Federated States of Micronesia due to chief complaint of difficulty breathing.
The problem started about three months prior to admission when she started to complain of chest heaviness accompanied by difficulty breathing and shortness of breath. She has been admitted in a local hospital in her country and was diagnosed to have COPD or Chronic Obstructive Pulmonary Disease and was discharged after being stable.
COPD is a progressive disease that makes it hard to breathe. “Progressive” means the disease gets worse over time. (source NHLBI)
After a month, she was re-admitted due to left sided pleuritic pain and was diagnosed with Community Acquired Pneumonia. She was responsive to IV antibiotics and manifested clinical improvements hence discharged.
Until ten days after being discharged, she complained of bilateral chest discomfort associated with shortness of breath and easy fatigability with positive 2-3 pillow orthopnea. She was then referred to our institution suspecting Coronary Artery Disease, congestive heart failure, to consider pulmonary embolism and pulmonary carcinoma.
The patient cannot speak English and only through her husband we could learn what is troubling her.
She was able to tolerate pulling urine flow of about 2.3 to 2.8 per session which is the target until her last session where her blood pressure drop down to 80s systolic. After pulling about 800cc of fluid, she became unstable. Dopamine drip was started on her to bring her BP up and he was brought back to her room for further evaluation.
Since she is anuric or does not produce urine, she was also referred to a kidney specialist called the nephrologist for dialysis three times a week.
She has been referred to a pulmonologist who ordered for a chest CT scan which revealed normal findings. Then, doctors suspected reproductive cancer involvement which prompted to think of referral to an Obstetrician Gynecologist. Considering ovarian cancer and multiple myeloma, the nehprologist request to run some tests on her such as the CA-125 and Serum protein electrophoresis.
According to medicine.com CA 125 is a protein that is a so-called tumor marker or biomarker, which is a substance that is found in greater concentration in tumor cells than in other cells of the body. In particular, CA 125 is present in greater concentration in ovarian cancer cells than in other cells.CA stands for cancer antigen measured through blood sample
The result was insignificant but the Serum protein electrophoresis particularly the gamma globulin proteins test was particularly high. This test measures the types of protein in the fluid (serum) part of a blood sample.
Serum proteins are classified as albumin or globulins. Albumin is the protein of highest concentration in the serum. It carries many small molecules, but is also important for keeping fluid from leaking out from the blood vessels into the tissues that is why it is called the gate keeper.
Increased gamma globulin proteins may indicate:
• Multiple myeloma
• Chronic inflammatory disease (e.g., rheumatoid arthritis, SLE)
• Hyperimmunization
• Acute infection
• Waldenstrom’s macroglobulinemia
• Chronic liver disease
Patient also started to complain of back pain. The nephrologist suggested to refer the patient to a haematologist of a blood disease specialist. The following day, the haematologist ordered for a bone marrow biopsy through bone marrow aspiration. The patient was placed on side lying position assuming a shrimp or fetal position to open the spinal cord. Through bone marrow aspiration a small amount of bone marrow fluid and cells are collected through a needle put into a bone. The bone marrow fluid and cells are checked for problems with any of the blood cells made in the bone marrow this time biopsy was made. Blood disorders such as leukemia, certain anemias, or problems that affect the bone marrow, such as multiple myeloma or polycythemia vera can be determined and staged.
The sample was sent to another hospital as we do not have the facility to perform such as test. Two days went on and the result came in Thursday morning and it was confirmed that the patient has Multiple myeloma is which is a cancer of the plasma cells in bone marrow. Plasma cells help the body’s immune system fight disease by producing proteins called antibodies. In multiple myeloma, plasma cells grow out of control in the bone marrow and form tumors in the areas of solid bone.
The growth of these bone tumors makes it harder for the bone marrow to make red blood cells, white blood cells, and platelets. This causes anemia, which makes a person more likely to get infections and have abnormal bleeding. (source medline.com)
The haematologist said that patient’s case had less than 40% survival and the insurance will no longer cover expenses for such a case. Nevertheless, the specialist wanted to start her on oral chemotherapy ASAP.
But things happened so quickly. That night, the patient complained on difficulty breathing, also she has been placed on non-invasive ventilator (NIV) she was so restless that she kept on pulling the face mask. We have instructed her husband to convince her to keep the face mask in place to help her breathe. The patient progressively became restless that she pulled everything including her IV line. Her acid-blood gas revealed respiratory acidosis and sodium bicarbonate needed to be pushed through IV line. The bedside nurse then was trying her hardest to tame the patient and to insert a new IV line. She went out to get help from a fellow nurse but when she came back, the patient was pulseless. She immediately performed chest compression and instructed the other nurse to sound a code. Efforts to revive her failed. She was pronounced dead at 1:35 in the morning.
Final diagnosis was: Acute Cardiorespiratory Failure, COPD, Chronic Renal Failure (End Stage Renal Disease), Multiple Myeloma.