Multiple MyelomaUrgent

65-year-old with 3 months of back pain and fatigue; Hb 82 g/L, creatinine 3.1 mg/dL, corrected calcium 12.8 mg/dL, total protein 9.2 g/dL, rouleaux on the film

• Leg weakness, sensory level, sphincter disturbance
• Corrected calcium >14 mg/dL
• Oliguria
• Blurred vision, mucosal bleeding (hyperviscosity)

• MGUS / smouldering myeloma
• Metastatic bone disease
• AL amyloidosis
• Waldenström (IgM hyperviscosity)
• Primary hyperparathyroidism

• Admit: Hypercalcaemia, AKI, cord compression, hyperviscosity, severe anaemia, infection
• ICU: Hyperviscosity with neuro signs, severe AKI with complications, sepsis
• Dialysis: Cast nephropathy with AEIOU indications
• Transfuse: Symptomatic anaemia (group & screen before daratumumab)

• "CRAB": Calcium high, Renal failure, Anaemia, Bone lesions — back pain + anaemia + high protein in an older adult is myeloma until proven otherwise.
• Light-chain cast nephropathy is reversible if light chains fall quickly — treat within days.
• Infection is the leading early cause of death — vaccinate, give antiviral prophylaxis, treat fevers promptly.

• Give NSAIDs or IV contrast casually in suspected myeloma
• Delay dexamethasone and MRI when cord compression is suspected
• Start daratumumab before a group & screen with extended phenotype
• Give zoledronate without a dental review when possible

• Missing CRAB features
• Nephrotoxins
• Skeletal survey instead of cross-sectional imaging
• No group & screen before daratumumab

Ward for CRAB emergencies; haematology-led induction; transplant assessment.