Skill Checkup: An Elderly Man With Leg Pain and Weakness

Maria-Victoria Mateos, MD, PhD; Simon J. Harrison, MBBS, PhD


April 04, 2022

The Skill Checkup series provides a quick, case-style interactive quiz highlighting key guidelines- and evidence-based information to inform clinical practice.

A 79-year-old retired White male schoolteacher presents with bone pain and increasing weakness. He is 5 ft 8 in and weighs 88 kg (body mass index = 29.8). He has a history of ischemic stroke at age 72 years and has been on warfarin and statin therapy with no stroke recurrence for 7 years. His gait remains labored with chronic walking dysfunction despite physical therapy. About 3 years ago, he had been diagnosed with multiple myeloma (MM; Bence Jones kappa ISS-2, R-ISS 2) after a tibial fracture of the right leg led to a full workup. Initial cytogenetic analysis revealed del17p positivity. The patient was considered ineligible for autologous stem cell transplant at that time. Instead, he was treated with eight 21-day cycles of a first-line regimen known as BLd, which consists of bortezomib, lenalidomide, and low-dose dexamethasone. He then received ongoing maintenance with lenalidomide for 21 days. The lenalidomide maintenance regimen was continued for 30 months. Dexamethasone was discontinued after the first eight induction cycles to make the maintenance regimen simpler and easier to tolerate. He has been regularly monitored since the initial diagnosis and now presents with new-onset bone pain in both legs, as well as increasing weakness.


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