Basic Diagnostic Algorithm

The main clinical presentations include low back pain, anaemia syndrome with the finding of normocytic anaemia, manifestations of renal insufficiency, recurrent sepsis or an incidental finding of a “100“ erythrocyte sedimentation rate, not decreasing.
The possibility of multiple myeloma should be considered in all these patients and they should be examined using the basic laboratory panel and X-ray.
Laboratory investigations should focus on the potential presence of “100/h“ ESR, hypercalcemia, isolated ALP elevation, hyperproteinemia, renal insufficiency, and urinary protein. The crucial test is electrophoresis, possibly complemented with immunofixation. When monoclonal gammopathy is confirmed and present together with the other listed symptoms, urgent haematological investigation is absolutely critical.
A simple X-ray scan is enough to identify typical osteolytic lesions or compression vertebral fractures. X-ray thus continues to be the mainstay examination technique of diagnostic radiology. Other techniques to be potentially used in the case of unclear results include NMRI, CT, PET, and MIBI.
NOTE – scintigraphy is not helpful in the diagnosis of myeloma.

Do not disregard the so-called common low back pain complaints.
Be always alert to the possibility of vertebral malignancy either by solid tumour metastasis or by multiple myeloma.

There should be no more medical history reports such as:
“I am 58 years old, and have had appreciable back pain. I had repeat courses of rehabilitation therapy including mobilization, painkiller injections with the orthopedician, and examination by a neurologist. It was not until I developed sudden paralysis of my legs that physicians using X-ray discovered degradation of several vertebrae with spinal cord oppression“.
It is mandatory to identify the cause of each case of anaemia. A “hundred“ ESR should invariably be considered an alarming symptom. Each patient with renal insufficiency should have the serum and urinary protein electrophoresis test.

“I have been treated by my general practitioner for about a year for red blood cell deficiency, I was receiving iron for a couple of months, to be followed by folic acid and vitamin B12. It was not until I had developed severe pneumonia coupled with swelling of my legs and persisting high erythrocyte sedimentation rates over 100/h that I was diagnosed to have myeloma. By that time, however, I had developed complete renal failure and now I have to have regular haemodialysis“.