Follow-up
Bictegravir/emtricitabine/tenofovir alafenamide treatment was immediately started. Dermatologist consultation evaluating skin desquamative-erythematous and itchy lesions diagnosed mild to moderate vulgaris psoriasis and recommended topical therapy with calcipotriol and betamethasone. The patient was then discharged in mild clinical condition with outpatient cardiological and internal medicine follow-up within 10 days after discharge. Cardiac therapy at discharge was based on furosemide 50 mg and bisoprolol 2.5 mg daily. Moreover, a bone marrow biopsy was scheduled. At the follow-up visit, patient lower limbs edema had worsened and high-grade proteinuria was stable. Spironolactone 50 mg/day and losartan 12.5 mg/day were then prescribed. Due to persistent mild hypotension (95/60 mmHg), losartan and spironolactone were soon suspended, furosemide dosage was increased up to 150 mg/day and dapaglifozin 10 mg was then started with subsequent significant decrease in lower limbs edema. One month after discharge, Doppler ultrasound of lower limbs showed resolution of DVT. Bone marrow biopsy revealed 30% CD138+, CD20-, CD56-/+, D1 Cyclin- monoclonal plasma cells with no sign of amyloid infiltration expressing lambda light chain. After obtaining viral load suppression, the patient is going to start bortezomib-based induction therapy plus daratumumab.