A 65-year-old Thai male presented with low back pain and weight loss for 1 month. 
Laboratory investigations revealed acute kidney injury with hypercalcemia.
BM biopsy is as shown above. 

Questions: 

1. Please describe the bone marrow biopsy
2. Please give the most relevant differential diagnosis
3. What is the plan for further investigations for diagnosis? 
4. What is the most proper acute management? 

ANSWERs

1. Bone marrow biopsy description

• Hypercellularity 
• Monoclonal eccentric nucleus with perinuclear halo (plasma cell)

2. Most relevant differential diagnosis:  Multiple myeloma

3. Plan for further investigations for diagnosis 

1. Serum protein electrophoresis (SPEP)

2. Immunofixation 

3. Serum free light chain (SFLC)

4. Bone survey films (skull, CXR, CTLS spine, pelvis, both humerus, both femur)

4. Acute management

• Evaluation of hyperviscosity syndrome by looking for signs of end organ damage, including stroke, heart failure, renal failure, and give supportive treatment 
• Treatment of hypercalcemia 
  • Aggressive IV hydration 
  • Calcitonin 4 units/kg IV q12h
  • Dexamethasone 40 mg/d (10 mg IV q6h); dexamethasone being the drug of choice for treatment of hypercalcemia in MM

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