Atypical Presentation of Multiple Myeloma in a 43-Year-Old Male: Sudden-Onset Body Ache with Acute Kidney Injury, Hypercalcemia, and No A/G Reversal

Abstract

Background: Multiple myeloma (MM) is a plasma-cell malignancy characterized by anemia, bone pain, renal dysfunction, and hypercalcemia. It may rarely present acutely with nonspecific complaints such as body ache or vomiting.

Case Presentation: A 43-year-old male presented with sudden-onset generalized body ache for 3 days and two episodes of vomiting for 1 day, associated with acute worsening of renal function. Laboratory evaluation showed severe anemia (hemoglobin 5.4 g/dL), hypercalcemia (14.9 mg/dL), and a rise in serum creatinine from 1.45 to 2.45 mg/dL within 2 days. Total leukocyte count was 7,560/mm³ and platelet count 236,000/mm³. Serum total protein was 6.4 g/dL with normal albumin and no albumin-to-globulin (A/G) reversal. Parathyroid hormone (PTH) was suppressed (<4 pg/mL), vitamin D was 22 ng/mL, and ACE levels were normal. PET-CT revealed multiple lytic skeletal lesions. Findings were consistent with plasma-cell dyscrasia, likely multiple myeloma.

Conclusion: This case demonstrates an acute and atypical presentation of multiple myeloma with body ache, vomiting, renal dysfunction, and hypercalcemia, but no A/G reversal. MM should be considered even when classical biochemical features are absent.

Introduction

Multiple myeloma (MM) is a malignant proliferation of plasma cells that accounts for approximately 10% of hematologic malignancies. The disease is characterized by CRAB features—hyperCalcemia, Renal dysfunction, Anemia, and Bone lesions ¹.

While the presentation is typically gradual, some patients develop acute metabolic derangements leading to sudden symptoms such as bone pain, vomiting, and renal impairment. This case highlights a 43-year-old man presenting with 3 days of body ache and recent vomiting, who was subsequently found to have MM without the classical A/G reversal.

Case Presentation

A 43-year-old male presented with sudden-onset generalized body ache for 3 days and two episodes of vomiting for 1 day. The vomiting was non-bilious and non-bloody. He also complained of fatigue and malaise. There was no history of fever, weight loss, or chronic illness. He denied use of nephrotoxic medications and had no history of diabetes or hypertension.

Clinical Examination

The patient was pale but hemodynamically stable. There was no lymphadenopathy or organomegaly. Diffuse bony tenderness was noted over the axial skeleton; neurological examination was normal.

Investigations

• Urinalysis revealed mild proteinuria without casts.
• Whole-body PET-CT demonstrated multiple lytic lesions involving the skull, vertebrae, ribs, pelvis, and long bones with increased FDG uptake suggestive of malignant involvement.

Based on the findings, a diagnosis of plasma-cell dyscrasia (probable multiple myeloma) was made. Serum protein electrophoresis, immunofixation, and bone-marrow biopsy were planned for confirmation.

Differential Diagnosis

• Multiple myeloma / plasma-cell dyscrasia
• Metastatic carcinoma (no primary lesion detected on PET)
• Sarcoidosis (normal ACE, no granulomatous lesions)
• Primary hyperparathyroidism (suppressed PTH)

Diagnosis

• The combination of hypercalcemia, anemia, acute kidney injury, and lytic bone lesions met the CRAB criteria for multiple myeloma ^1,2.
• The absence of A/G reversal raised the possibility of a non-secretory or oligosecretory variant ².

Management and Outcome

• The patient was treated with aggressive intravenous hydration and zoledronic acid for hypercalcemia. Packed red blood cell transfusions were administered for anemia correction.
• After hematology consultation, planned for bone marrow biopsy, initiation of bortezomib + cyclophosphamide + dexamethasone (VCD regimen) was initiated⁴.
• Renal function partially improved following correction of calcium and treatment initiation. The patient was discharged with plans for regular follow-up and consideration for autologous stem-cell transplantation.

Discussion

Multiple myeloma often presents with bone pain, anemia, renal dysfunction, and hypercalcemia¹. Vomiting and generalized body ache, as seen in this case, are nonspecific but can be early manifestations of hypercalcemia and renal dysfunction².

The acute rise in serum creatinine indicated acute kidney injury (AKI), likely due to hypercalcemia-induced nephropathy and possible light-chain cast deposition²^,³.

Although A/G reversal (low albumin, high globulin) is a common biochemical hallmark of MM¹, its absence (total protein 6.4 g/dL with normal albumin) may occur in:

Early/smoldering disease with minimal M-protein production⁴, or

Non-secretory/oligosecretory myeloma, which accounts for 1–5% of MM cases⁴^,⁵.

Suppressed PTH excluded primary hyperparathyroidism, normal ACE ruled out sarcoidosis, and PET-CT findings confirmed osteolytic skeletal disease consistent with MM³.

Prompt correction of hypercalcemia, management of AKI, and initiation of anti-myeloma therapy are key to preventing irreversible kidney damage and improving prognosis².

Conclusion

This case illustrates an atypical, acute presentation of multiple myeloma in a 43-year-old male with generalized body ache, vomiting, hypercalcemia, and acute kidney injury, but no A/G reversal. Clinicians should consider MM in patients with unexplained hypercalcemia and renal dysfunction, even in the absence of classic biochemical findings¹^,². Early diagnosis and treatment are crucial for better outcomes.

References

1. Chawla SS, Kumar S, Dispenzieri A, Greenberg AJ, Larson DR, Kyle RA, et al. Clinical course and prognosis of non-secretory multiple myeloma. Eur J Haematol. 2015;95(1):57‑ doi:10.1111/ejh.12454
2. Shah M, Perazella MA. AKI in multiple myeloma: paraproteins, metabolic disturbances, and drug toxicity. J Onco-Nephrol. 2017;1(3):188‑ doi:10.1007/s12308-017-0293-x
3. Ayar Y, Ersoy A, Yildiz A. Multiple myeloma kidney. Turk J Nephrol. 2015;24(3):256‑ doi:10.5505/tjn.2015.55820
4. Hamidah N, Azma RZ, Ezalia E, Das S, Umar NA, Swaminathan M, et al. Non-secretory multiple myeloma with diagnostic challenges. Clinica Terapeutica. 2010;161(5):445‑ doi:10.7417/CT.2010.635
5. Charliński G, Jurczyszyn A. Non-secretory multiple myeloma: diagnosis and management. Adv Clin Exp Med. 2022;31(1):95‑ doi:10.17219/acem/133101
6. Kumar S, Pérez WS, Zhang MJ, Ballen K, Bashey A, To LB, et al. Comparable outcomes in non-secretory and secretory multiple myeloma after autologous stem cell transplantation. Bone Marrow Transplant. 2018;53(9):1150‑ doi:10.1038/s41409-018-0164-2

Dr. C. Chaitra
2nd Year DNB Nephrology,
Kauvery Hospital, Alwarpet, Chennai.[1]

Dr. Balaji Kirushnan
Senior Consultant Nephrologist,
Kauvery Hospital, Alwarpet, Chennai.[1]