Hyperviscosity is thought to cause Vertigo by peripheral vestibular involvement causing vascular obstruction in the venules. Most patients do not exhibit symptoms until viscosity is greater than 4 centipoises and those symptoms can be subtle until viscosity is greater than 5. Its hallmark features include bleeding, ocular symptoms and neurological findings which include vertigo like our patient. Accroding to a review article published in Thrombosis and Hemostasis in 2003, symptomatic hyperviscosity is only present in about 2-6% of Multiple Myeloma patients being much more common in Waldenstroms Macroglobinemia. Hyperviscosity is related to the greatly elevated monoclonal protein levels. She subsequently was started on chemotherapy and received plasmapheresis.ĭiscussion: Vertigo is a common complaint in the ER setting often requiring an inpatient hospital stay for symptom management, however it is rarely the initial presenting symptom of Multiple Myeloma secondary to hyperviscosity syndrome. A serum viscosity was checked and noted to be 4.3 centipoises (expected 5.6 centipoises. Given these new findings, hyperviscosity syndrome was thought to be a cause of her symptoms. She had a bone marrow biopsy preformed confirming Multiple Myeloma. An MRI brain was preformed showing T1-2 hyperintensities consistent with lytic lesions and a subsequent protein electrophoresis was positive for IgA monoclonal protein (5231 mg/dl). Her laboratory findings were benign except for a hypercalcemia of 10.8 mg/dl, a creatinine of 1.78 mg/dl (baseline 1.4) and a protein gap of 8.1 (TP 10.6 g/dl, Albumin 2.5 g/dl). She had a full neurological examination and had no focal physical exam findings to suggest either a peripheral or central cause of vertigo. Her symptoms were extreme and she could no longer walk secondary to nausea and imbalance. She failed Epley Maneuvers and did not respond to meclizine. Over the next few days, her blood pressure was improving however her severe vertigo persisted. In the ER she was noted to have a Blood pressure of 208/103 and therefore was admitted to our observation unit for further blood pressure management and symptom control. She denied any other associated symptoms. She reported light headedness with frequent room spinning while ambulating. Case Presentation: 84 year old previously healthy female with history of hypertension, Diabetes and chronic kidney disease stage 2 presented to the ER with dizziness.
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