A 60-year-old patient presented in Emergency, intubated from another hospital along with GCS 3, hepatic encephalopathy, hepatitis B positive, pancytopenia with haemoglobin count around 4, sepsis, tumour lysis syndrome, dyselectrolytemia and coagulopathy. He was shifted to MICU immediately. After that, he was transfused with multiple RDP, PRBC, FFP.

We gave him optimum antibiotic cover with all types of life support. MRI brain and MRI spine suggested multiple myelomatous lesions, extensively spread all over the body with mainly brain metastasis. In intubated state, I did the bone marrow procedure, which showed aggressive multiple myeloma with 85% plasma cells.

The gastro team took care of hepatic encephalopathy and hepatitis B status. For 7 days, there was no improvement in the sensorium, and EEG showed encephalopathy. TLS parameters improved and dyselectrolytemia improved with all sorts of correction. Bone marrow and biochemical evaluation revealed multiple myeloma, IgA kappa, ISS stage III.

Then we started VCD chemotherapy. After one cycle with high-dose Dexa, he started bleeding from the abdomen. We did CT abdomen angiography which showed multiple areas of bleeding. So, we had to reduce the Dexa dose to 20 mg. After 3 sets of chemotherapy, his hemodynamical status and sensorium improved. Slowly, he was extubated and all types of life support removed.

But at this point, there was a constant drop in haemoglobin. We even thought of doing embolization of the right Iliac artery bleeding area. But on the day of the procedure, no active bleeding site was found. Slowly his haemoglobin count was stabilized and he was able to eat and talk slowly.

After administering Day 15 chemotherapy with VCD regimen, he was hemodynamically stable without any IV medication. So, he was discharged around Day 17, on oral antibiotics and supportive medicines with catheter in situ. The family was very happy. They still couldn't believe he was going home alive. I am grateful to the gastro team, the ICU team and the BMT team for their constant support, and finally, the NSH management for offering a sizeable discount on the total bill.