Case of the Month #26: Myeloma Pain by Dr Sonia Pierce

Mr T was assessed by the patient’s local pain service’s multidisciplinary team. This was a joint initial assessment with a doctor in pain medicine and a specialist physiotherapist. He told them his story of pain, explaining that he had suffered with persistent low back pain on an off for many years. His pain normally settled down after a few weeks and although he had taken some time off work in years gone by, he had always managed it with a some co-codamol and exercise until it settled. This time, his pain started higher up his back and didn’t settle after the usual few weeks. He found twisting movements would exacerbate his pain, sometimes causing a searing sensation through his back. He also noted an intermittent dull ache, which extended around his rib cage to his upper abdomen. Now, six months later, he admitted he was struggling, and he had been unable to work in his role as a hospital porter. He was feeling exhausted all the time and now struggled to climb stairs. 

He was taking co-codamol 30/500 regularly and occasional ibuprofen, although it was of minimal benefit. He was on no other medication; he had no other significant past medical history and his appetite was normal. He explained that he and his wife were trying to eat healthily, and he was pleased he had been successful at losing some weight, despite being less active. His pain was impacting significantly on his quality of life, found it more difficult to sleep at night because of pain and he was concerned about losing his job. On examination, Mr T reported pain on palpation of his mid to low thoracic spine but there was no abnormal neurology or other abnormal findings. 

• What are the “red flag” features in this patient’s history?
• What are your differential diagnoses?
• What would you consider when formulating a management plan with Mr T?