Common in older adults - median age 60 years; M >F
Presenting clinical features include symptoms of: (1,2,3)
- bone disease
- patients may initially present with unexplained backache or bone pain
- long bones, ribs, skull, and pelvis are also commonly involved
- may present as a pathologic fracture (26 to 34% of patients) following minimal trauma, especially of the femoral neck
- weakness and paraesthesias in the lower extremities due to vertebral compression fractures
- carpal tunnel syndrome - the most common peripheral neuropathy associated with multiple myeloma
- anaemia
- fatigue and malaise
- recurrent or persistent bacterial infection
- due to suppression of antibody production and neutropenia
- commonly with encapsulated organisms such as Streptococcus pneumoniae, Haemophilus influenzae;
- hypercalcaemia
- nausea, fatigue, confusion, polyuria, constipation
- renal failure
- occurs in 20 to 40% of patients
- due to direct tubular damage from excess protein load, dehydration, hypercalcemia, and the use of nephrotoxic medications
- aggravated by hypercalcaemia
- weight loss
- occurs in less than one fourth of patients
- hyperviscosity -
- mucosal bleeding, vertigo, nausea, visual disturbances, alterations in mental status
- hyperviscosity syndrome is more common in IgA than IgG disease
- fever
It is important to remember that around 34% of patients are asymptomatic at presentation and are diagnosed following the incidental detection of a raised ESR, plasma viscosity, serum protein or globulin, creatinine, calcium, or haemoglobin laboratory panels
On examination:
- bone tenderness may be present at the sites of growth
- occasionally soft tissue masses
- neuropathy related to tumourous infiltration of nerve root trunks - symmetric sensorimotor, gradual in onset, and progressive, with pain and dysesthesia (impairment of any sense, especially touch) in limbs; more common in men
- lymphadenopathy and splenomegaly are exceptional
- hepatomegaly is common
References:
- Dimopoulos MA, Moreau P, Terpos E, et al. Multiple myeloma: EHA-ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. Ann Oncol. 2021 Mar;32(3):309-22.
- NICE. Myeloma: diagnosis and management. NICE guideline NG35. Published february 2016, last updated October 2018.
- Sive, J., Cuthill, K., Hunter, H., Kazmi, M., Pratt, G., Smith, D. and (2021), Guidelines on the diagnosis, investigation and initial treatment of myeloma: a British Society for Haematology/UK Myeloma Forum Guideline. Br. J. Haematol., 193: 245-268.