A 60 year‐old woman presents with a 3 day history of weakness and shortness of breath. Associated symptoms include pain in her back, occiput, and chest, as well as subjective fevers and presyncope.
Her medical history was significant for remote intravenous drug use, current opiate abuse, and a chronic pain syndrome that had not been given a specific diagnosis.
Her temperature is 102 degrees Farenheit, blood pressure 80/palpation, and heart rate 134. She is cachectic and her body mass index is 16. Her lungs revealed crackles and there was bony tenderness of the spine. She required non‐invasive positive pressure to sustain pulse oximetry above 95%. After initial resuscitation with fluids, antibiotics, and vasopressors, her condition rapidly stabilized.
Labs revealed: albumin 2.3g/dL, total protein 7.5g/dL, creatinine 5.2mg/dL, white blood cell count 13.6 cells/mL, hemoglobin 9.2g/dL, and platelets 134,000 platelets/mL. Chest X‐ray revealed bilateral infiltrates and a lung mass. Serology for Hepatitis C was positive. Blood cultures grew pipercillin resistant E. Coli. Serum electrophoresis revealed an M‐spike, urine electrophoresis did not. Bone marrow biopsy demonstrated normal FISH chromosomal markers and many plasma cells; Micro B2‐globulin was 10. Skeletal survey demonstrated diffuse lesions. CT demonstrated a large mass attached to the chest wall and lytic lesions of the spine, occipital bone, and T3. MRI of the lumbar spine revealed malignant infiltration of the spine. CT guided biopsy confirmed plasmacytoma of the chest wall.
The original presentation was classic septic shock secondary to a pneumonia. Initial resuscitation with fluids and antibiotics treated her presenting symptoms. Culture results confirmed a gram negative rod bacteremia. Many of her laboratory abnormalities were thought to be a product of her undiagnosed Hepatitis C and acute reaction to profound sepsis. As her mentation returned and her bone pain became more apparent, further investigation into her lung mass and laboratory abnormalities revealed an underlying and widely distributed cancer.
Given her history of prescription narcotic abuse, withdrawal of these medications was expected to worsen her symptoms. But what was that pain from? She had an intense nociceptive pattern of pain, which was peculiar given little external signs of tissue trauma. The pain’s location was peculiar as well: in her mid back and her long bones of her legs and arms. The degree of pain and tenderness in her extremities was incongruent with sepsis or hepatitis, diagnoses for which the protein gap, elevated creatinine, and thrombocytopenia could be attributed. The x‐ray was impressive for her pneumonia and masked the mass on initial presentation. The acuity of her initial presentation distracted the team from paying attention to the normocytic anemia, the renal failure, and bone pain that represent three of the four CRAB criteria in the diagnosis of multiple myeloma. Only by stepping back and reassessing the clinical picture after her initial resuscitation was there the ability to reconsider a more insidious diagnosis.
Intuitive reasoning permitted assessment and treatment of the septic shock; analytical reasoning allowed diagnosis of a more insidious disease