What is the proper workup for an elderly patient with a history of multiple myeloma, presenting with vertigo, recent ear tube (tympanostomy tube) placement for fluid buildup, and symptoms of headache, mild coordination impairment, low-grade fever, severe coordination issues, vomiting, increased lethargy, and forgetfulness?

From the Guidelines

The proper workup for this elderly patient with multiple myeloma and concerning neurological symptoms should begin with urgent neuroimaging, preferably an MRI of the brain with and without contrast, to evaluate for potential central nervous system involvement, as the patient's symptoms of severe coordination issues, vomiting, increased lethargy, and forgetfulness suggest a possible CNS infection or myeloma progression with CNS involvement. Given the patient's history of multiple myeloma, vertigo, and recent ear tube placement, a comprehensive evaluation is necessary to determine the cause of the patient's symptoms. The workup should include:

• A complete blood count, comprehensive metabolic panel, blood cultures, and serum and urine protein electrophoresis to assess myeloma status 1
• A lumbar puncture to evaluate for meningitis, particularly given the patient's immunocompromised state and presence of fever, with CSF analysis for cell count, protein, glucose, cytology, flow cytometry, and cultures
• Vestibular testing, including electronystagmography, to characterize the vertigo
• An otologic examination to assess the ear tubes and look for evidence of infection
• Empiric antimicrobial therapy should be considered while awaiting culture results, typically with broad-spectrum antibiotics such as vancomycin plus ceftriaxone or cefepime, with consideration of antifungal coverage, due to the patient's immunocompromised state and progressive neurological symptoms. It is essential to prioritize the patient's morbidity, mortality, and quality of life, and given the severity of the patient's symptoms, a prompt and comprehensive workup is necessary to prevent further neurological deterioration. The patient's recent ear tube placement and history of multiple myeloma increase the risk of infection, and the presence of fever and neurological symptoms suggests a possible CNS infection or myeloma progression with CNS involvement, which requires prompt diagnosis and management. Therefore, a comprehensive and urgent workup, including neuroimaging, lumbar puncture, and empiric antimicrobial therapy, is necessary to determine the cause of the patient's symptoms and prevent further neurological deterioration.

From the Research

Patient Presentation

The patient is an elderly individual with a history of multiple myeloma, presenting with vertigo, recent ear tube placement for fluid buildup, and symptoms of headache, mild coordination impairment, low-grade fever, severe coordination issues, vomiting, increased lethargy, and forgetfulness.

Differential Diagnosis

Given the patient's complex presentation, a thorough workup is necessary to determine the underlying cause of their symptoms. Possible considerations include:

• Meningitis, given the symptoms of headache, fever, and coordination impairment 2
• Central nervous system involvement of multiple myeloma, which can cause a range of neurological symptoms 3
• Infection or other complications related to the recent ear tube placement

Diagnostic Approach

A comprehensive diagnostic approach may include:

• Lumbar puncture (LP) to analyze cerebrospinal fluid (CSF) for signs of infection, inflammation, or malignancy 2, 4, 5
• CSF culture and polymerase chain reaction (PCR) to identify potential pathogens 2
• Blood cultures to identify bacteremia or other systemic infections 2, 4
• Imaging studies, such as MRI or CT scans, to evaluate for potential central nervous system involvement or other complications

Considerations for CSF Analysis

When interpreting CSF results, it is essential to consider the potential effects of antibiotic pretreatment on CSF profiles 4. Additionally, the presence of traumatic lumbar puncture may require correction of CSF white blood cell counts to accurately diagnose meningitis 5.

Prognostic Indicators

Repeat CSF examination may be a useful prognostic indicator in patients with bacterial meningitis, as delayed sterilization of CSF has been associated with adverse outcomes 6. Similarly, the presence of raised intracranial pressure (ICP) in patients with cryptococcal meningitis may require repeated therapeutic lumbar punctures as adjunctive management 3.

Next Steps

Given the complexity of the patient's presentation, a multidisciplinary approach involving neurology, infectious disease, and hematology specialists may be necessary to determine the underlying cause of their symptoms and develop an appropriate treatment plan.