Discriminating clinical features

MGUS—no symptoms or signs, normal FBC and biochemical profile, paraprotein level <30g/L and stable, no immuneparesis (rarely present), BM plasma cells <10%, no lytic lesions.

Plasmacytoma—localised bone pain, low paraprotein level, isolated bony lesion.

Myeloma—symptoms and signs of anaemia or hyperviscosity (ffl p510); bone pain or tenderness, raised Ca2+, creatinine, urate; high |3-2 microglobulin and low albumin; immuneparesis; paraprotein >30g/L of IgG or >20g/L of IgA or heavy BenceJones proteinuria; BM >10% plasma cells; lytic bone lesions on x-ray. Minimum diagnostic criteria are at least 2 of emboldened items.

Plasma cell leukaemia—as myeloma but fulminant history. Plasma cells seen on blood film.

Heavy chain disease—rare, characterised by a single heavy chain only in serum or urine electrophoresis. Presence of any light chain excludes.

Amyloid—myriad clinical features. Diagnosis on biopsy of affected site or, if inaccessible, by BM or rectal biopsy—characteristic fibrils stain with Congo Red and show green birefringence in polarised light.

CLL and NHL—systemic symptoms e.g. fever, night sweats, weight loss. Lymphadenopathy or hepatosplenomegaly likely. Confirm on BM or node biopsy.

Waldenstrom's—as for CLL but with symptoms or signs of hyperviscosity (ffl p284).

Autoimmune disorders—suggested by joint pain, skin rashes, multisystem disease. Confirm on autoimmune profile including rheumatoid factor, ANA, ANCA.

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