SHM Converge Scientific Abstract ePoster Gallery-When Persistent Symptomatic Hypotension Does Not Make Sense

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This case describes a 79-year-old woman with a history of non-ischemic cardiomyopathy, chronic kidney disease, hypertension, hypothyroidism, pulmonary hypertension, obesity, and hyperlipidemia who presented with 2 weeks of worsening dizziness and bilateral leg edema. She had stopped diuretics and carvedilol for months because of persistent hypotension. Over the prior year, she also had major unintentional weight loss (70 pounds), generalized weakness, early satiety, and dry mouth.  <br /><br />On presentation, she was hypotensive (90/60 mmHg) with pitting edema and bibasilar crackles, but without orthostatic changes or focal neurologic deficits. Initial workup showed thrombocytopenia, acute worsening of renal function, and markedly elevated BNP. Extensive evaluation for autoimmune and infectious causes was negative. Imaging showed volume overload, pleural effusions, and anasarca. Echocardiography demonstrated severe concentric wall thickening, severe global left ventricular dysfunction, restrictive diastolic physiology, pulmonary hypertension, and a small pericardial effusion.  <br /><br />Because her hypotension persisted despite treatment, she required midodrine, compression stockings, and later milrinone after right heart catheterization confirmed elevated right-sided pressures. Due to unexplained weight loss, GI malignancy was investigated, but colonoscopy and endoscopy were unrevealing aside from a small tubular adenoma.  <br /><br />A hematologic workup revealed an M-spike on SPEP, and immunofixation identified an IgG lambda monoclonal protein. Bone marrow biopsy showed 20% monoclonal plasma cells on aspirate and 25–30% plasma cell infiltration on biopsy, consistent with a plasma cell neoplasm, i.e., multiple myeloma.  <br /><br />The key teaching point is that multiple myeloma can present atypically with dysautonomia and persistent symptomatic hypotension, even without classic CRAB features. In patients with unexplained hypotension, weight loss, multiorgan involvement, or possible neuropathic/autonomic symptoms, plasma cell dyscrasia should be considered early.

Asset Subtitle

Cristine K. Arcilla

Meta Tag

Author List Cristine K. Arcilla, Daniel Goldsmith, Elmer S. Gamboa, Gelareh Wintermyer, Madhav Acharya, Natalia Plotskaya

Category Clinical Vignettes

Concept Hypotension

Concept Multiple Myeloma

Concept Autonomic Dysfunction

Concept Plasma Cell Neoplasm

Concept Weight Loss

Distinguished Non-Finalist

Presenter Organization Capital Health Regional Medical Center

Presenting Author Cristine K. Arcilla

Track Adult

Keywords

multiple myeloma

dysautonomia

hypotension

monoclonal gammopathy

plasma cell neoplasm

weight loss

cardiomyopathy

renal dysfunction

IgG lambda

autonomic symptoms

Hypotension

Multiple Myeloma

Autonomic Dysfunction

Plasma Cell Neoplasm

Weight Loss