Dear Doctor,

I write as one of you, a Family Practice physician for 25 years.  I dealt with the same vague CC's which you do: "Why am I so tired"?, Why don't I feel good"?, and "Why does my back still hurt"?  Near the end of my practice I missed an important Dx......my own......by failing to include Multiple Myeloma in my Differential Diagnosis. My increasing back pain ultimately resulted in a T-10 compression fx.

The plea in this short note is simple: better awareness. Please keep your Index of Suspicion high for this zebra hiding among so many common horses.  If your patient doesn't respond to the conservative approach you recommend, please order a simple SPEP (serum protein electrophoresis).  It is not part of a routine chem panel, but will quickly rule out this devastating diagnosis. An IFE (immuno fixation electrophoresis) is helpful to confirm and define your patients' cancerous clone which is producing myeloma protein.

Also recall the acronym for myeloma diagnosis. CRAB reminds us to remember (1)HyperCalcemia, (2)Renal disease, (3)Anemia, and (4)Bone disease. When combined with lab values showing a monoclonal spike of a single immunoglobulin, the diagnosis is active multiple myeloma.

Please don't miss this important diagnosis. Myeloma should be on your long Diff Dx list for chronic back pain, frequent infections, and extreme fatigue.

Sincerely,

Jim Omel MD