Question

What is the likely diagnosis in a patient who has low back ache, L3 tenderness, and the following data: total proteins 8.9 g/dL, albumin:globulin ratio 2.9/5.9 (reversed), serum creatinine 5.5 mg/dL, TLC 4500/mm3, DLC neutrophils 55%, lymphocytes 40%, eosinophils 2%; blood urea was 93 mg/dL and serum creatinine was 1.2 mg/dL; ESR was 90 mm in the first hour?

• A. Waldenstrom's macroglobulinemia
• B. Multiple myeloma
• C. Amyloidosis
• D. Bone secondaries

Hint:

A reversed albumin to globulin ratio with a very high ESR and bone tenderness points to a plasma cell disorder with bone involvement.

Answer 1

The Correct Option is B

This patient has back pain with L3 tenderness, a reversed albumin to globulin ratio, raised creatinine, and an ESR of 90. Let's weigh each option against these clues.

1. Waldenstrom's macroglobulinemia: A clonal IgM disorder that usually causes hyperviscosity features like blurred vision and mucosal bleeding, not lytic bone disease or vertebral tenderness, so it does not match this picture well.
2. Multiple myeloma: A plasma cell clone overproduces one type of globulin, which flips the albumin to globulin ratio, makes red cells clump and pushes ESR very high, damages the kidney through light chain injury, and eats away at bone causing localized pain and tenderness exactly like the L3 finding here.
3. Amyloidosis: Can occur alongside myeloma, but on its own does not explain the reversed A:G ratio or the vertebral tenderness in this vignette.
4. Bone secondaries: Explain bone pain but not the reversed A:G ratio or the very high ESR, since there is no paraprotein driving those changes.

Every clue, reversed A:G ratio, sky-high ESR, renal impairment, and vertebral tenderness, lines up with multiple myeloma.

Let's summarize:

• A reversed A:G ratio with a very high ESR signals a paraprotein-producing plasma cell clone.
• Vertebral tenderness plus renal impairment in this setting points to myeloma bone and kidney disease.

The likely diagnosis is multiple myeloma.