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Management of a 56-Year-Old HIV Positive Man with Severe Back Pain and Monoclonal Gammopathy

This case involves a 56-year-old man diagnosed with HIV since 1997, currently asymptomatic with 840 CD4 count and low viral load. He presents with acute mid-thoracic back pain and MRI shows compression fractures. Further evaluation uncovers spinal osteoporosis, anemia, and renal function decline. A skeletal survey reveals a lytic skull lesion, and urine tests indicate monoclonal proteins. A bone marrow biopsy confirms 80% monoclonal plasma cells. The patient will receive radiotherapy, chemotherapy, and undergo an autologous stem cell transplant.

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Management of a 56-Year-Old HIV Positive Man with Severe Back Pain and Monoclonal Gammopathy

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  1. CASE 5 • 56 yr-old man • HIV + 1997 • Asymptomatic • CD4 840 HIV viral load <40 • ABC/3TC/Efavirenz

  2. CASE 5 • Sudden onset of severe, sharp lancinating mid thoracic back pain • MRI reveals T8/L5 compression fracture • Bone scan negative for lesions • Dexa scan reveals spinal osteoporosis…T score -3.4

  3. CASE 5 • Hb decreased from 145 to 110 (normocytic) over last 6 months without obvious cause • Creatinine increased from 70 to 176 micromole/l

  4. CASE 5 • Anemia workup for all usual causes negative • u/s kidneys…normal sized kidneys…no obstruction • u/a…non active sediment • alb/creatinine…14 (<2 normal) • Prot/creatinine….0.150g/l (ULN)

  5. CASE 5 What would you do?

  6. CASE 5 • Skeletal survey…14mm punched out lytic lesion in skull • Urine immunoelectrophoresis reveals 8.4 gm protein/24 hrs with free monoclonal kappa light chain proteins (bence jones) accounting for 50% of protein with reminder being glomerular in nature

  7. CASE 5 • Confirmatory bone marrow biopsy reveals 80% monoclonal plasma cells

  8. CASE 5 • Will receive radiotherapy to spinal compression fractures • Will undergo chemotherapy followed by autologous stem cell transplant • Bisphosphonate therapy

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