Multiple myeloma differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: {}HMHJ} {AE} Haytham Allaham, M.D. [2] Shyam Patel [3]

Overview

Multiple myeloma must be differentiated from other causes of bone lesions such as osteoporosis, osteomalacia, scurvy, osteogenesis imperfecta, and homocystinuria. Each condition has unique causes, features, and treatment.

Differentiating Multiple Myeloma from other Diseases

• The table below summarizes how to differentiate multiple myeloma from other conditions that have a similar presentation:

Differential Diagnosis Causes Features Therapy Multiple myeloma Chromosomal aberrations or other genetic insults Malignant transformation of plasma cells Clonal plasma cell proliferation Diffuse bone pain and tenderness with osteolytic lesions Renal failure Hypercalcemia Anemia Induction chemotherapy with bortezomib, lenalidomide, and dexamethasone Bisphosphonates RANK ligand inhibitors (denosumab) Autologous stem cell transplantation Monoclonal gammopathy of undetermined significance (MGUS) Chromosomal aberrations or other genetic insults Clonal plasma cell proliferation Asymptomatic Serum M protein of <30 g/L Fewer than 10% plasma cells in the bone marrow No evidence of bone or organ damage Observation Asymptomatic Plasma Cell Myeloma (Smoldering and Indolent plasma cell myeloma) Chromosomal aberrations or other genetic insults Malignant transformation of plasma cells Clonal plasma cell proliferation Asymptomatic Serum M protein of >30 g/L Greater than 10% plasma cells in the bone marrow No evidence of bone or organ damage Observation Plasma Cell Leukemia Chromosomal aberrations or other genetic insults Malignant transformation of plasma cells Renal failure Hypercalcemia Cytopenias No bone lesions Chemotherapy Plasmacytoma Chromosomal aberrations or other genetic insults Malignant transformation of plasma cells Solitary bone plasmacytoma (bone) Extramedullary plasmacytoma (soft tissues) Clinical manifestations related to tumor mass and compression symptoms Surgery Osteoporosis Imbalance between bone resorption and bone formation Preceded by osteopenia Decreased bone mineral density Acute musculoskletal pain if fractures develop Severe decrease in BMD on dual-energy X-ray absorptiometry (DEXA) test T score less than -2.5 on DEXA scan Calcium and vitamin D supplementation Bisphosphonates Weight-bearing exercise Teriparatide RANK ligand inhibitors (denosumab) Osteomalacia Inadequate mineralization of bone Deficiency of vitamin D calcium, or phosphorus Renal tubular acidosis Malabsorption Diffuse bone pain, fatigue, and fractures Low bone mineral density (BMD) Hypocalcemia Vitamin D3 supplementation Scurvy Vitamin C deficiency Malabsorption Hemodialysis Gum disease such as gum bleeding Loose teeth Easy bruising Impaired immune response Impaired wound healing Vitamin C supplementation Citrus fruits Osteogenesis imperfecta Mutations in COL1A1 or COL1A2 Impaired type I collagen synthesis Short stature, scoliosis, and propensity for fractures Blue discoloration of sclera Bisphosphonates Physical therapy Surgical fixation of brittle bones Genetic counseling for offspring Homocystinuria Deficiency of cystathionine beta synthase Deficiency of folate, vitamin B12, or vitamin B6 Diffuse bone pain and musculoskeletal symptoms High-dose vitamin B6 supplementation Betaine supplementation

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