In the latest of our monthly series, Dr Henna Taimoor asked readers to suggest what was the cause of this elderly woman’s back pain, fever and right flank pain symptoms. Answers below!
This 73-year-old Asian female patient presents to you for the first time during a busy GP clinic with back pain, fever and right flank pain symptoms. Initial examination reveals discomfort in the right flank suggesting UTI and renal infection.
The patient’s urine dip is positive for leucocytes, nitrites and blood. You treat her for suspected pyelonephritis, prescribing oral cefalexin for one week and arranging review to follow up in one week.
You order baseline tests including renal function and a urine culture.
At review the next week the patient’s feverish symptoms have-resolved, while her back pain had improved It had not resolved and she is feeling quite fatigued.
The blood workup reveals a drop in haemoglobin to 98 g/dl, down from 120 g/dl a few months ago, a normal white cell count and normal renal function.
Urine culture confirms E coli sensitive to cefalexin. A repeat urine dip shows persistent non-visible haematuria blood 3+ despite the infection-having been resolved.
Looking through the patient’s notes you see she has a-past medical history of breast cancer diagnosed 15 years prior; she underwent successful wide local excision and radiotherapy followed by tamoxifen for five years.
She has no other significant past history – no history of smoking or alcohol or significant occupational exposures. However, you note she presented last year with back pain and left sided chest wall pain which were thought to be muscular and managed with analgesia by a colleague.
In view of the fatigue and anaemia, you start her on oral iron replacement for symptomatic relief, arrange tests to rule out bowel causes of anaemia and organise another follow-up appointment.
At review a few weeks later she mentions she still has symptoms of ongoing back pain fatigue and mainly right flank/right side lumbar area. There is no shortness of breath, no chest pain, no leg swelling and she is feeling a bit better on oral iron, but still tired.
Physical examination is unremarkable, with normal vital signs and no palpable abdominal or pelvic masses.
Breast examination shows scar of previous left sided surgery, no new breast lumps and no palpable axillary nodes.
Weight is stable (BMI 26). Bowel test results are back showing both FIT and calprotectin were negative.
You dip the urine again today to see if infection could be the cause of back pain and again it is negative for all but blood 3+.
Answer
I arranged a CT KUB to rule out renal cancer or calculi.
At the same time I also arranged myeloma screening bloods, as I could not explain her symptoms and presentation fully, and whether this had any link with her back pain.
The CT KUB showed no stones – but picked up multiple healing left-sided rib fractures. It also picked up degenerative changes within the imaged skeleton, non-specific sclerosis around the pubic symphysis and a healing fracture of the T12 vertebral body (there was no history of trauma).
I discussed these findings with the patient and wrote to the breast team urgently to investigate possible secondaries from breast cancer presenting like this.
Concurrently the following week myeloma screen results came back which was deranged unexpectedly!
Serum free light chain was significantly abnormal, with a serum kappa light chain level 9848.090 mg/L, and a serum kappa/lambda light chain ratio of1627.78.
I then arranged an urgent referral to haematology with findings above and the patient’s diagnosis of multiple myeloma was confirmed.
She is now doing well and on treatment for multiple myeloma.
Discussion: This case illustrates an atypical presentation of multiple myeloma.
Renal involvement in multiple myeloma can manifest as cast nephropathy, hypercalcemia, or light-chain deposition disease, contributing to non-visible haematuria.
Persistent non-visible haematuria in elderly patients warrants thorough investigation to rule out malignancies.
Back pain, fatigue, anaemia and atypical symptoms in elderly patients should warrant a suspicion for myeloma
Comprehensive evaluation, including serum protein electrophoresis and bone marrow biopsy, is essential for an accurate diagnosis. Early recognition and treatment of multiple myeloma are crucial for improving patient outcomes.
Dr Henna Taimoor is a GP in Derby
I would consider an urgent x-ray of the back/ chest to see if there are any secondaries. If that comes back negative, I would consider a DEXA scan and vitamin D if not done already. I would also consider a myeloma screen and FIT test for anaemia.
Age 73, Microscopic haematuria, lumbar pain, fatigue, Asian background – I would suggest urine for cytology, CRP, ESR, sputum for AFB,, X-ray thoracic-lumbar spine and CT abdomen possibility of underlying tuberculosis should be excluded
given previous history of left sided chest pain and persistent back pain aortic anuyrism should be considered in differntial diagnosis
1. Renal cancer
2. Mets
3. Myeloma
CT chest abdo/pelvis
Hyperneprhoma (as per ‘Scottish GP’ above) seems quite possible given age, symptoms and persistant haematuria with anaemia. An urgent CT abdo (+ as others have suggested usual bloods and TB screens).
I’d refer to rapid diagnostic centre for CT TAP and MR Spine. There could be mets to the spine and kidneys causing back pain and microscopic haematuria.
I’d refer to rapid diagnostic centre for CT TAP and MR Spine. There could be mets to the spine and kidneys causing back pain and microscopic haematuria.
Multiple myeloma can also cause back pain and microscopic haematuria. If lymph nodes are enlarged that can also cause hydronephrosis and risk of kindney infection
Endocarditis
Endocarditis with septic emboli causing renal infarction and discitis