Question
8gm%. A bone marrow examination was ordered the next day. What is the most likely possibility in such a situation What are the findings expected in a bone marrow examination What are the laboratory investigations you will do to arrive at a diagnosis and what are the expected results What are the complications of this disease (2+3+6+4)
Answer
This is a continuation of the clinical case in printedNumber 1 of this paper (elderly man with fatiguability, bone pain, decreased urination, pallor, Hb 8 g%, normal TLC/platelets, marked rouleaux formation, ESR 110 mm/1st hour) — the most likely diagnosis being Multiple Myeloma.
Most likely possibility
- Multiple myeloma (plasma cell neoplasm)
Expected bone marrow findings
- Increased plasma cells (>10% of marrow cellularity, often much higher)
- Plasma cells showing atypical/abnormal morphology — binucleation, prominent nucleoli, perinuclear hof loss, eccentric nuclei, “flame cells”
- Sheets or clusters of plasma cells replacing normal haematopoietic tissue
Laboratory investigations and expected results
- Serum protein electrophoresis: M-spike (monoclonal band, usually IgG or IgA)
- Urine Bence Jones protein: Positive (free monoclonal light chains, kappa or lambda)
- Serum free light chain assay: Abnormal kappa/lambda ratio
- Skeletal survey/imaging: Multiple punched-out lytic lesions (skull “raindrop skull,” vertebrae, pelvis, long bones)
- Serum calcium: Elevated (hypercalcaemia from osteolysis)
- Serum creatinine/renal function: Elevated (myeloma kidney/cast nephropathy)
- Beta-2 microglobulin: Elevated (prognostic marker)
- Peripheral smear: Rouleaux formation (as already noted), normocytic normochromic anaemia
Complications of multiple myeloma
- Renal failure (“myeloma kidney” — cast nephropathy, hypercalcaemia-related nephrotoxicity, AL amyloidosis)
- Recurrent bacterial infections (functional hypogammaglobulinaemia despite high total immunoglobulin)
- Pathological fractures (from lytic bone lesions)
- Hypercalcaemia (weakness, confusion, polyuria, constipation)
- Hyperviscosity syndrome (bleeding, visual disturbances, neurological symptoms)
- Amyloidosis (AL type, from light chain deposition)
- Spinal cord compression (from vertebral involvement/collapse)