![]() ![]() Renal impairment occurs in 20–40% of newly diagnosed patients with myeloma, and is typically due to light chain deposition within the distal and collecting renal tubules or hypercalcaemia. If PTH levels are appropriately suppressed, an alternative explanation such as myeloma must be considered. Some laboratories also offer PTH related peptide assays to exclude paraneoplastic hypercalcaemia. 3 Alternative aetiologies should be excluded with a laboratory assay for intact parathyroid hormone (PTH), which should be suppressed in response to the hypercalcaemia, and vitamin D levels. Profound elevations in serum calcium can rarely lead to coma or cardiac arrhythmia. Symptomatic hypercalcaemia may present in a dramatic fashion with confusion, disorientation, muscle weakness, constipation, anorexia, polyuria and polydipsia. 2 The serum calcium level should always be interpreted after correction for albumin. Hypercalcaemia is a less frequent manifestation of myeloma at diagnosis, occurring in approximately 13% of patients. Routine haematinics are normal and rouleaux may be noted on the blood film. The anaemia of multiple myeloma is typically normochromic and normocytic, but mild macrocytosis can also be seen. Alternatively, an asymptomatic, but persistent, anaemia may be detected on routine bloods. 1 Patients with significant anaemia may present with fatigue, dyspnoea on exertion or angina. A combination of these symptoms should heighten diagnostic suspicion for myeloma.Īnaemia is found in approximately 70% of those with newly diagnosed myeloma. The classical complications are often abbreviated into the acronym ‘CRAB’: consisting of hypercalcaemia, renal impairment, anaemia and bony lesions. The clinical presentation of multiple myeloma can be extremely varied. How can multiple myeloma and MGUS present? Multiple myeloma Usually required to confirm a diagnosis of multiple myelomaĪ small proportion of cases may be non-secretory with undetectable paraprotein No clear explanation including pre-renal causes, primary renal disorders or obstructive conditions No history of malignancy, sarcoidosis or use of medications such as thiazides Parathyroid hormone appropriately suppressed No clear alternative explanation such as renal impairment or anaemia of chronic disease Vitamin B12, folate and iron studies normal When should a diagnosis of myeloma be considered? Finding Monoclonal gammopathy of undetermined significance is defined as a serum paraprotein of 30 g/L or a bone marrow plasmacytosis of >10% ( Table 1). MGUS and smouldering myeloma are asymptomatic with no evidence of end organ damage. Trephine showing infiltration with malignant plasma cells You must thank me today for bringing happiness in your life.Figure 1B. “Warm wishes on Bhai Dooj to you brother. “You are my brother and I am truly thankful to you because no one else can handle me. “This world would have been such a boring place had you not been there with me. “Warm wishes on Bhai Dooj to my dearest brother who never missed even one opportunity to annoy me.” ![]() “Make it a memorable Bhai Dooj by not fighting because we are good siblings.” “You are the most amazing brother in this world because I am the luckiest sister in this universe. Lots of love and warm wishes on Bhai Dooj to you.” Bhai Dooj Caption for brother “Celebrations of Bhai Dooj are seriously awesome when we two are together.” “Without you, the occasion of Bhai Dooj has no meaning to me. “Bhai Dooj reminds me that I am blessed to have a sister like you who is so sweet. “Together we can pull the best of the pranks. “You make the coolest sister because I am the smartest brother. “Brothers and sisters are like the inseparable friends for life. “Life feels alive when you have a brother or sister to share it with. “Cheers to all the crazy things that we have done together. “There is no one like you because there is no one like me. “Only we two can tolerate each other because we are brothers and sisters. “Why do I only have such weird childhood memories with you. ![]() “Let us make it a memorable Bhai Dooj by celebrating it with the loving siblings who make this occasion a special one.” Funny Bhai Dooj Caption for Instagram “This world is a better place if you have brothers and sisters to share your joys with. “There is no one in this world who has pestered me more than you. Enjoy this day with your brothers and sisters.” ![]() “Together, we make the deadliest combination. “Having a brother is like a blessing in disguise. Share these unique Bhai Dooj captions for Instagram and warm Bhai Dooj messages with your dearest siblings. We have come up with a collection of funny Bhai Dooj captions for sisters and brothers. Have the funniest and cutest Bhai Dooj captions shared on Instagram with siblings to express how much you love them. The celebrations of Bhai Dooj are special when you have warm Bhai Dooj messages and Bhai Dooj quotes to share with brothers and sister. ![]()
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