From the Guidelines
Multiple myeloma with epistaxis and easy bruising is primarily caused by thrombocytopenia, which is a result of bone marrow infiltration by the cancer, and the patient should be evaluated immediately by a hematologist-oncologist for management of both the myeloma and bleeding complications. The symptoms of epistaxis and easy bruising in multiple myeloma patients are often related to thrombocytopenia, which is a common complication of the disease 1. Thrombocytopenia can be caused by bone marrow infiltration by the cancer, coagulation factor deficiencies, hyperviscosity from excess paraproteins, and platelet dysfunction.
Causes of Thrombocytopenia
- Bone marrow infiltration by the cancer
- Coagulation factor deficiencies
- Hyperviscosity from excess paraproteins
- Platelet dysfunction
Initial treatment should include platelet transfusion if thrombocytopenia is present, with a target platelet count above 50,000/μL. For epistaxis, direct pressure to the anterior nasal septum for 15 minutes, followed by topical vasoconstrictors like oxymetazoline nasal spray, can provide immediate relief. Systemic antifibrinolytics such as tranexamic acid (1g IV or PO every 8 hours) may be needed to control bleeding. The underlying myeloma requires prompt treatment with standard regimens like VRd (bortezomib, lenalidomide, dexamethasone) or DRd (daratumumab, lenalidomide, dexamethasone) 1.
Treatment Approach
- Platelet transfusion for thrombocytopenia
- Direct pressure and topical vasoconstrictors for epistaxis
- Systemic antifibrinolytics for bleeding control
- Prompt treatment of underlying myeloma with standard regimens
Correcting hypercalcemia and renal dysfunction, which often accompany myeloma, is also essential for managing bleeding risk. Regular monitoring of complete blood counts, coagulation studies, and paraprotein levels will guide ongoing treatment decisions. Infections are a major cause of morbidity and mortality in multiple myeloma patients, and prophylactic antibiotics may be considered in certain cases, especially during the first three months of therapy with immunomodulatory drugs (IMiDs) like lenalidomide and pomalidomide 1.
From the FDA Drug Label
Bortezomib is associated with thrombocytopenia and neutropenia that follow a cyclical pattern with nadirs occurring following the last dose of each cycle and typically recovering prior to initiation of the subsequent cycle Gastrointestinal and intracerebral hemorrhage has occurred during thrombocytopenia in association with bortezomib. Thrombocytopenia was reported in 32% of patients Thrombocytopenia was Grade 3 in 22%, ≥ Grade 4 in 4%, and serious in 2% of patients, and the reaction resulted in bortezomib discontinuation in 2% of patients
The cause of multiple myeloma with epistaxis (nosebleed) and easy bruising, also known as thrombocytopenia (low platelet count), is thrombocytopenia associated with bortezomib treatment. This is a known side effect of bortezomib, which can lead to a decrease in platelet count and increase the risk of bleeding, including epistaxis and easy bruising 2 2.
From the Research
Causes of Multiple Myeloma with Epistaxis and Easy Bruising
The causes of multiple myeloma with epistaxis (nosebleed) and easy bruising, also known as thrombocytopenia (low platelet count), can be attributed to several factors. Some of the key factors include:
- Abnormal coagulation profile, which can manifest as life-threatening hemorrhagic complications 3
- Dysfibrinogenemia, paraprotein-induced platelet dysfunction, shortened platelet survival, damage to the vascular endothelium, and acquired von-Willebrand syndrome 3
- Acquired dysfibrinogenemia, resulting in laboratory abnormalities and/or bleeding complications 4
- Monoclonal plasma cell proliferation, which can lead to end organ injury and failure, including anemia, bone pain, renal injury, fatigue, hypercalcemia, and weight loss 5
Mechanisms of Bleeding Tendencies
The mechanisms of bleeding tendencies in multiple myeloma can be explained by:
- Dysfibrinogenemia, which can lead to hemorrhagic complications 3, 4
- Paraprotein-induced platelet dysfunction, which can cause easy bruising and bleeding 3
- Shortened platelet survival, which can contribute to thrombocytopenia 3
- Damage to the vascular endothelium, which can lead to bleeding complications 3
- Acquired von-Willebrand syndrome, which can cause bleeding tendencies 3
Clinical Presentations
The clinical presentations of multiple myeloma with epistaxis and easy bruising can vary, ranging from few symptoms to end organ injury and failure. Some common presenting findings include: