24 Sept 2026
Patient history
A 68-year-old woman has four months of worsening lower back pain that now wakes her at night and no longer responds to paracetamol. She is exhausted, constipated and has lost 5 kg, and her family say she seems muddled in the afternoons. She has had two chest infections in six months.
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Multiple myeloma
Bortezomib-based induction (bortezomib, lenalidomide and dexamethasone)
Back pain that wakes a 68-year-old at night and no longer answers to paracetamol is not mechanical, and the constipation, exhaustion and afternoon muddle beside it are one complaint rather than three: a calcium of 12.4 mg/dL. With the anemia and a creatinine of 2.3 mg/dL, the CRAB tetrad is complete. Several details then separate myeloma from its mimics. A normal alkaline phosphatase alongside extensive lytic disease is characteristic: myeloma lesions come from osteoclast activation with osteoblasts suppressed, so there is no reparative bone formation to raise the ALP or light up an isotope scan. That is why the negative scan misleads and why skeletal survey or whole-body CT is the right imaging; metastatic carcinoma provokes an osteoblastic reaction and is usually scan-positive. A suppressed parathyroid hormone excludes primary hyperparathyroidism as the cause of hypercalcemia. The very high total protein with low albumin, marked rouleaux and an ESR over 100 all reflect the circulating paraprotein. Recurrent infections follow from immunoparesis, visible here as suppressed IgA and IgM. The diagnosis requires clonal plasma cells of 10% or more plus end-organ damage; at 42% with clear CRAB features this is symptomatic myeloma, not MGUS or smouldering disease. The t(4;14) on FISH marks high-risk cytogenetics, and a beta-2 microglobulin of 6.8 mg/L with an albumin of 2.9 g/dL puts her at an advanced stage. Induction is a bortezomib-based triplet with lenalidomide and dexamethasone, the proteasome inhibitor mattering most here because it partly offsets the prognosis t(4;14) carries, followed by autologous stem cell transplant if she is fit enough. Supportive care weighs as heavily: bisphosphonates, hydration for the calcium and kidneys, prompt treatment of infection, and radiotherapy for intractable bone pain or the cord compression that the L2 wedge fracture makes a live concern.