Primary refractory patientHistory

Lynne is a 39 year old single mother of two children (age 9 and 6) who works as the manager of a private day nursery. She lives in a small market town in Lincolnshire.

In June 2011 Lynne started getting regular nosebleeds and went to see her GP. She also reported that she’d had a productive cough for the last six weeks and had been feeling increasingly tired over the last two months. She had no other complaints or health concerns and thought her symptoms were related to the stress of juggling her job with family life.

On examination, she appeared pale. Blood results revealed anaemia with a haemoglobin level of 88 g/L (range 120 – 160 g/L); lowered WBC of 2.8 x 109/L (range 4 – 11 x109/L) and neutrophil count of 0.9 x 109/L (range 2.5 – 7.5 x 109/L), and a platelet count of 198 x 109/L (range 150 – 400 x 109/L).

Her serum creatinine (109 mmol/L; range 60 – 126 mmol/L) and calcium (2.19 mmol/L; range 2.12 – 2.65 mmol/L) levels were both normal but her serum total protein was elevated to 96 g/L (range 60 – 84 g/L).

Based on the elevated protein, a serum protein electrophoresis was subsequently ordered and showed an IgG concentration of 79g/L and the presence of a monoclonal spike of 61g/L.

As a result Lynne was referred to the haematology department of the local district hospital for further assessment. Further tests revealed a serum β2 microglobulin was 3.7 mg/L (range 0.3 – 1.9 mg/L) and albumin was 33 g/L (range 35 – 50 g/L).

Her bone marrow biopsy showed 80% involvement of abnormal appearing plasma cells, confirmed by CD56+ and cyclin D1+ immunohistochemical staining.

A complete skeletal survey showed no lytic lesions and no focal lesions were detected by MRI of the thoracic and lumbar regions.

According to the International Staging System, Lynne was classified with Stage II myeloma and Stage IIIA by the Durie Salmon Staging System.