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 Serum Immunoelectrophoresis IGGIGAIGM Monoclonal kappa spike accounting for 20% of IgG… suppression of other Igs 6.310.180.11 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