Our anaemic patient has a small paraprotein (IgG lambda, 4.6g/L). When finding a paraprotein it is important to think of the differentials:

• MGUS
• Asymptomatic myeloma
• Plasma cell myeloma AKA multiple myeloma or simply myeloma
• Non-Hodgkin lymphoma (e.g. Waldenström’s macroglobulinaemia)
• POEMS syndrome (polyneuropathy, organomeglay, endocrinopathy, M protein, skin)
• Bone or extramedullary plasmacytoma
• Amyloid

In order to diagnose myeloma there needs to be end organ damage. The so-called CRAB features:

• Hypercalcaemia
• Renal failure
• Anaemia
• Bone lesions

She is anaemic but has a number of reasons to be so and has no other features clinically. She has no palpable lymphadenopathy and no other symptoms of lymphoma. POEMS syndrome is rare and the symptoms do not fit.

A number of our followers have raised the possiblity of amyloid….

Questions

• What are the symptoms of amyloid?
• What further investigations does the patient need to rule out myeloma?

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