What is the management approach for a patient with multiple myeloma (indicated by Mott cells) and pulmonary tuberculosis?

Management of Multiple Myeloma with Pulmonary Tuberculosis

Treat both conditions simultaneously—initiate anti-tuberculosis therapy immediately upon diagnosis while proceeding with appropriate multiple myeloma treatment, as delays in either condition significantly increase mortality risk.

Immediate Tuberculosis Management

Start anti-tuberculosis therapy immediately without waiting for myeloma treatment initiation, as this is critical for reducing transmission risk and preventing progression 1. The key principle is that effective treatment rapidly reduces infectiousness within days of appropriate therapy 2.

Isolation and Infection Control

• Isolate the patient immediately in a negative pressure room until diagnostic workup confirms drug susceptibility 2
• Patient should wear a surgical mask when outside the isolation room to reduce droplet nuclei transmission 1
• Early molecular testing for drug resistance is essential—standard treatment will not render MDR-TB patients non-infectious 2
• De-isolation can occur once sputum microscopy is negative on appropriate therapy, though timing depends on drug susceptibility results 2

Anti-TB Treatment Principles

• Never add a single drug to a failing regimen—this causes acquired resistance 1
• Continue chemotherapy for 1-2 years, even if surgical intervention becomes necessary 1
• If surgery is required for TB complications (empyema, diagnostic biopsy), ensure several months of intensive chemotherapy first 1

Multiple Myeloma Diagnostic Workup

Complete the full diagnostic evaluation despite active TB 2:

Essential Laboratory Studies

• CBC with differential, platelets, BUN, creatinine, electrolytes, calcium, albumin, LDH, β2-microglobulin 2
• Serum protein electrophoresis (SPEP), serum immunofixation (SIFE), quantitative immunoglobulins 2
• 24-hour urine for total protein, UPEP, UIFE 2
• Serum free light chain assay with kappa/lambda ratio 3

Bone Marrow and Imaging

• Unilateral bone marrow aspirate and biopsy with immunohistochemistry/flow cytometry 2
• Cytogenetics and FISH [del 13, del 17, t(4;14), t(11;14), t(14;16)] 2
• Full skeletal survey (avoid contrast CT due to potential renal impairment) 2
• MRI for suspected vertebral compression or to distinguish active disease 2

Staging

Use Durie-Salmon classification and International Prognostic Index (combining β2-microglobulin and albumin) 2

Multiple Myeloma Treatment Strategy

For Transplant-Eligible Patients (Age ≤65, Good Performance Status, No Renal Failure)

High-dose therapy with autologous stem cell transplantation is standard 2:

• Induction with VAD-based regimens (vincristine, adriamycin, high-dose dexamethasone) or newer triple-agent regimens (bortezomib, lenalidomide, dexamethasone) 2, 3
• High-dose melphalan 200 mg/m² IV as preparative regimen (preferred over melphalan 140 mg/m² plus TBI) 2
• Use peripheral blood progenitor cells rather than bone marrow 2

For Non-Transplant Candidates (Elderly, Comorbidities)

Oral melphalan-prednisone remains standard 2:

• Melphalan 9 mg/m²/day for 4 days plus prednisone 30 mg/m²/day for 4 days 2
• Repeat cycles every 4-6 weeks until stable response 2
• Multiagent chemotherapy is NOT superior and may be inferior in elderly patients 2

Critical Supportive Care

Long-term bisphosphonates (oral or IV) are mandatory for stage III or relapsed disease to reduce skeletal events 2

Infection Risk Management in Myeloma Patients

Myeloma patients have 7-fold increased bacterial infection risk and 10-fold increased viral infection risk 2. This is compounded by active TB.

Antibiotic Prophylaxis Considerations

• Consider routine antibiotic prophylaxis for the first 3 months when using lenalidomide or pomalidomide with dexamethasone 2
• Particularly important given concurrent TB and aggressive disease 2
• No specific antibiotic regimen is mandated, but avoid interference with TB medications 2

Monitoring

• Thorough infection monitoring throughout treatment 2
• Watch for Haemophilus influenzae, Streptococcus pneumoniae, Gram-negative bacilli, influenza, and herpes zoster 2

Treatment Sequencing Algorithm

1. Day 1: Isolate patient and start anti-TB therapy immediately 1, 2
2. Days 1-7: Complete myeloma diagnostic workup 2
3. Week 1-2: Initiate myeloma induction therapy once TB drug susceptibility is known and patient is stable 2, 3
4. Ongoing: Continue both treatments concurrently with close monitoring for drug interactions and cumulative toxicity 2

Critical Pitfalls to Avoid

• Do NOT delay TB treatment waiting for myeloma staging—mortality from untreated TB is immediate 1
• Do NOT use single-agent additions to either treatment regimen 1
• Do NOT assume negative bronchoscopy excludes TB in immunocompromised myeloma patients 4
• Do NOT discontinue isolation prematurely without confirming drug-susceptible TB and negative sputum microscopy 2
• Do NOT use multiagent chemotherapy in elderly patients—it worsens outcomes 2

Response Monitoring

• Assess myeloma response via serum/urine M-component electrophoresis and serum free light chains 2, 3
• Monitor TB response with sputum cultures and clinical improvement 2
• Serial measurements every 3 months for myeloma markers 2
• Bone marrow biopsy as clinically indicated 2