Some laboratories also offer PTH related peptide assays to exclude paraneoplastic hypercalcaemia. 3 Alternative aetiologies should be excluded with a laboratory assay for intact parathyroid hormone (PTH), which should be suppressed in response to the hypercalcaemia, and vitamin D levels. Profound elevations in serum calcium can rarely lead to coma or cardiac arrhythmia.

Symptomatic hypercalcaemia may present in a dramatic fashion with confusion, disorientation, muscle weakness, constipation, anorexia, polyuria and polydipsia. 2 The serum calcium level should always be interpreted after correction for albumin. Hypercalcaemia is a less frequent manifestation of myeloma at diagnosis, occurring in approximately 13% of patients. Routine haematinics are normal and rouleaux may be noted on the blood film. The anaemia of multiple myeloma is typically normochromic and normocytic, but mild macrocytosis can also be seen. Alternatively, an asymptomatic, but persistent, anaemia may be detected on routine bloods. 1 Patients with significant anaemia may present with fatigue, dyspnoea on exertion or angina. A combination of these symptoms should heighten diagnostic suspicion for myeloma.Īnaemia is found in approximately 70% of those with newly diagnosed myeloma. The classical complications are often abbreviated into the acronym ‘CRAB’: consisting of hypercalcaemia, renal impairment, anaemia and bony lesions. The clinical presentation of multiple myeloma can be extremely varied. How can multiple myeloma and MGUS present? Multiple myeloma Usually required to confirm a diagnosis of multiple myelomaĪ small proportion of cases may be non-secretory with undetectable paraprotein No clear explanation including pre-renal causes, primary renal disorders or obstructive conditions No history of malignancy, sarcoidosis or use of medications such as thiazides Parathyroid hormone appropriately suppressed No clear alternative explanation such as renal impairment or anaemia of chronic disease Vitamin B12, folate and iron studies normal When should a diagnosis of myeloma be considered? Finding Monoclonal gammopathy of undetermined significance is defined as a serum paraprotein of 30 g/L or a bone marrow plasmacytosis of >10% ( Table 1). MGUS and smouldering myeloma are asymptomatic with no evidence of end organ damage. Trephine showing infiltration with malignant plasma cells

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