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Old 04-05-2011
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Arrow High Yield Question #8

A 72 y/o man has experienced persistent dull back pain for 5 months, unrelated to physical activity. He has noted a 10 kg weight loss during this time. On physical examination there are no abnormalities. A CT scan of the spine reveals scattered 0.4 to 1.2 cm bright lesions in the vertebral bodies.

High Yield Question #8-ctspine.jpg
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Lab finding:
WBC count of 6700/microliter
differential of 70 segs, 8 bands, 2 metamyelocytes, 15 lymphs, 5 monos, and 2 nucleated RBCs/100 WBCs
Hgb 11.2 g/dL
Hct 33.3%
MCV 88 fL
platelet count 89,000/microliter.
urea nitrogen 35 mg/dL
creatinine 3.8 mg/dL
glucose 78 mg/dL

Which of the following additional laboratory test findings is he most likely to have:

A) Blood culture positive for Neisseria gonorrheae
B) Parathyroid hormone, intact, of 100 pg/mL
C) Serum prostate specific antigen of 35 ng/mL
D) Serum calcium of 5.5 mg/dL
E) Positive serology for Borrelia burgdorferi
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Old 04-05-2011
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C) PSA

I'm guessing he has prostate cancer that metastasized to his spine (most common location of metastasis). 10 kg weight loss was a big clue I think.

His renal function is really bad though, not sure if that changes the diagnosis
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Old 04-05-2011
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could be multiple myeloma
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Old 04-05-2011
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Quote:
Originally Posted by bash rcs View Post
could be multiple myeloma
I think mm would be lytic lesions rather than blastic lesions - I would choose PSA as well...
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Yea with any older patient presenting with back pain, MM should be on your differential but like Mondoshowan said, the x-rays would show lytic lesions rather than bright lesions.

I have shadowed in heme/onc and worked with a lot of MM patients. The lytic lesions are really obvious on x-rays. This x-ray doesnt look to have any lytic lesions. You would also expect to see compression fractures in the spine. This is the most common initial presentation of an MM patient.
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ya you guys are definitly right .. was thinking of MM because of the renal failure and thrombocyopenia ..
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Old 04-05-2011
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bone lesions + BUN/creatinine ratio

C) Serum prostate specific antigen of 35 ng/mL
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Arrow C) Serum prostate specific antigen of 35 ng/mL

You guys are pros! you all correct. I'm really impressed with the explanations.

C) Serum prostate specific antigen of 35 ng/mL

A prostatic adenocarcinoma should be the first guess (particularly in an older male!) with osteoblastic (bone-forming) tumor metastases. Extensive metastases can act as a myelophthisic process that leads to peripheral blood leukoerythroblastosis. His cancer may be causing urinary tract obstruction with renal failure.
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