Not Your Everyday Knee Pain - Page #4

Working Diagnosis:
Multiple Myeloma in a previously healthy 23 YO male.
6/10/10 - Presented to the ER with intractable R hip pain after a fall in church. Xrays revealed Protrusion of the R femoral head thru the acetabulum. Case Photo #6Case Photo #7
6/15/10 - Underwent Resection arthroplasty R femoral head and girdlestone

Underwent 2 drug Chemo regimen. Radiation. Decadron therapy. Autologous Stem Cell Transplant

Multiple myeloma is extremely rare in this age group. Only 0.3% of multiple myeloma patients are under 30. They have similar presentation and diagnostic studies however they tend to have more extramedullary involvement. Median survival is 4.5 years under 40 and 7 years for under 30 even with high dose chemotherapy, steroids and stem cell transplant.

Last Oncology note as of now was from 1/2011. Pt was doing well. He was progressing well with physical therapy. Continued to need pain medications and a cane. Was still on maintenance chemotherapy and due for re-staging at day 100 of stem cell transplant.

Author's Comments:
This is a very rare case. However it helped to do a thorough history and physical. As you can see he was complaining of knee pain but as we examined the joint above and below it became apparent that the etiology of his pain was coming from his hip.

Editor's Comments:
This case highlights the importance of maintaining a high index of suspicion for oncologic and infectious processes in patients where the level of pain exceeds the mechanism of injury.
On initial presentation this patient had no inciting event and on the second presentation had an event that should not have induced the level of pain he was experiencing.
It also undersocres the importance of examing the joint above and below the joint where the complaint lies. This is particularly important in patients complaining of knee/thigh pain as hip pathology can radiate pain to the thigh/knee.

-Blade K, Kyle RA. Multiple Myeloma in Young Patients: Clinical presentation and treatment approach. Leukemia and Lymphoma. 10/1997. Vol30. pp493-501
-Palumbo A, Anderson K. Multiple Myeloma. N Eng J Med. 2011. 364. 1046-1060
-Rajkumar SV. Clinical Features, laboratory manifestations and diagnosis of multiple myeloma. Up To Date. 1/2011

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