Clinical Opal #8 - Myeloma
Bob Georgiou, a 66-year-old retired university lecturer, presents to you with vague aches and pains, weight loss of a few kilograms and fatigue for the past couple of months. He puts it down to a recent stressful period with his daughter who is in the middle of a divorce. He denies any other symptoms on systems review, and examination is unremarkable.
His baseline bloods are within the normal range. You agree with Bob to watch and wait and review if anything changes.
Four months later, Bob presents to your colleague with bone pain and soon after is diagnosed with multiple myeloma. On reflection, you wonder whether you should have checked his calcium level and maybe other tests like an IEPG at baseline.
How does myeloma most commonly present? And what are some diagnostic tips to avoid missing this condition?
Multiple myeloma is part of a spectrum of plasma cell malignancies, ranging in severity from asymptomatic to aggressive. Myeloma commonly presents in a non-specific fashion – diagnosis is therefore commonly missed, with 50% of symptomatic patients having a delay of more than six months before diagnosis (>12 months in one third of cases)[i].
The symptoms and signs of myeloma result from plasma cells infiltration (myelosuppression from marrow infiltration, or hepatosplenomegaly), paraproteinaemia (hyperviscosity symptoms or peripheral neuropathy) or light chains in the serum (renal impairment).
The most common presenting symptoms or signs of myeloma include:
- Normochromic, normocytic anaemia—70% of patients
- Bone pain—60%
- Renal impairment—50%
- Fatigue—30%
- Weight loss—25%
- Hypercalcaemia—15%
Helpful diagnostic tips include:
- Consider myeloma in patients with a normochromic normocytic anaemia or unexplained raised ESR[ii]
- Exclude myeloma before making a diagnosis of PMR in elderly patients with a raised ESR
- Consider paraproteinaemia in the setting of an unexpectedly raised total protein concentration on LFT
- Be aware of the ‘CRAB’ symptoms (hypercalcemia, renal insufficiency, anaemia, bone lesions)
- Recurrent infections can be a presenting feature of myeloma
General practice is a tough gig.
We deal with newborns to centenarians, urology and neurology and (occasional) zoology, and emergencies to chronic disease management. Many of the presentations we see are undifferentiated, and, while uncommon, serious 'not to be missed' conditions must be reliably identified and managed.
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References:
[1] Hsu D C, Wilkenfeld P, Joshua D E. Multiple myeloma BMJ 2012; 344 :d7953 doi:10.1136/bmj.d7953
[1] Early detection of multiple myeloma in primary care using blood tests: a case–control study in primary care. Koshiaris C et al.,BJGP 2018; 68 (674): e586-e593.
Simon is a GP based in Newcastle, NSW, and a senior medical educator with Medcast. He also has medical education roles with the RACGP and GPSA.
Over the past three decades, Simon has worked in clinical and educational roles in NSW and the NT, as well as in the Republic of Ireland. He has published over 75 peer reviewed journal articles, and in 2018 received the RACGP Corliss award for his contribution to medical education.
Simon is passionate about high quality education and training. He has particular interests in GP supervisor professional development and the rational use of tests and medicines. He is a proud member of Doctors for the Environment. He spends his spare time drinking craft beer and pretending that he is a musician in the Euthymics, an all-GP band.
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