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This patient who presents with lower back pain with red flag symptoms (weight loss, waking up at night), as well as symptoms consistent with anemia (fatigue and conjunctival pallor), hypercalcemia (constipation), and abnormal plasma cell function (high Kappa/Lambda ratio) most likely has multiple myeloma. This disease would present with increased calcium, decreased phosphate, increased alkaline phosphatase, decreased PTH, normal PTH-rp, and decreased vitamin D levels. Multiple myeloma leads to numerous laboratory changes that can be used in combination to help diagnose the disease. Serum protein electrophoresis will reveal a monoclonal immunoglobulin spike (M protein). Urinalysis will show Ig light chains organized into eosinophilic substances known as Bence Jones protein. A peripheral blood smear will show Ig containing inclusion bodies in plasma cells (Russell bodies) as well as red blood cell Rouleaux formation. Bone marrow aspiration will show proliferation of large monoclonal plasma cells with a "fried egg" appearance. Finally, serology will reveal hypercalcemia due to cytokine-mediated osteoclastic activation. This hypercalcemia will lead to a compensatory decrease in parathyroid hormone and vitamin D production. Figure A presents the calcium, phosphate, alkaline phosphatase, parathyroid hormone (PTH), parathyroid hormone-related protein (PTH-rp), and vitamin D levels in the answer choices. Kinomura et al. present immunohistochemical staining of a patient with multiple myeloma demonstrating the production of parathyroid hormone-related protein in myeloma cells. This represents a case report where PTH-rp is involved in myeloma cells but this is not typical. Incorrect Answers: Answer 1: Decreased calcium, decreased phosphate, increased alkaline phosphatase, increased PTH, normal PTH-rp, and decreased vitamin D levels are consistent with vitamin D deficiency. This disease would present with diffuse bone pain and osteopenia. Answer 3: Increased calcium, decreased phosphate, increased alkaline phosphatase, increased PTH, normal PTH-rp, and increased vitamin D levels are consistent with primary hyperparathyroidism. This disease can present with diffuse bone pain accompanied by symptoms of hypercalcemia such as constipation; however, it would not result in anemia. Answer 4: Increased calcium, decreased phosphate, increased alkaline phosphatase, increased PTH, increased PTH-rp, and increased vitamin D levels are consistent with PTH-rp producing tumors such as small cell lung cancer. The localizing symptoms to the low back as well as anemia make multiple myeloma a more likely diagnosis for this patient. Answer 5: Increased calcium, increased phosphate, increased alkaline phosphatase, decreased PTH, normal PTH-rp, and increased vitamin D levels are consistent with hypervitaminosis D; however, this disease would present with isolated symptoms of hypercalcemia without accompanying anemia or bone pain. Bullet Summary: Multiple myeloma would present with increased calcium, decreased phosphate, increased alkaline phosphatase, decreased PTH, normal PTH-rp, and decreased vitamin D levels.
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