A 68-year-old Caucasian woman presented with acute renal failure, hypercalcaemia and serum monoclonal IgG κ. Computed tomography (CT) of her abdomen revealed bilateral nephromegaly with no evidence of obstruction (fig 1). Despite normal plain radiography, three dimensional tomographic reconstruction of her pelvis and lumbar spine showed multiple dramatic and punctated lesions, diagnostic of multiple myeloma (fig 2A,B). Serum protein electrophoresis in combination with immuno-electro-fixation revealed the presence of a monoclonal IgG κ and free κ light chains; the latter is also detected in urine. Appropriate chemotherapy was instituted but 6 months after the patient’s initial diagnosis, she remains on haemodialysis.

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Figure 1 Computed tomography (CT) of abdomen revealing bilateral nephromegaly with no evidence of obstruction.

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Figure 2 Three dimensional tomographic reconstruction of (A) pelvis and (B) lumbar spine showing multiple dramatic and punctated lesions, diagnostic of multiple myeloma.

Multiple myeloma is not an uncommon haematological condition and has a wide range of presentation, with ∼70% of patients having bone pain and lytic lesions. The lytic bone lesions (fig 2) are due to the increased turnover of osteoclastic activity which are stimulated by a number of factors including interleukins 1 and 6, receptor activator of nuclear factor–κβ ligand (RANKL), osteoprotogerin and macrophage inflammatory protein-1α.1 In addition, there is also significantly impaired osteoblastic response due inhibitory proteins such as dickkopf-1.2 These proteins are being explored as targets for novel anti-myeloma treatment. Most of these markers are not routinely measured in usual myeloma presentations. Parathyroid hormone related peptide has also been implicated, especially in the pathogenesis of hypercalcaemia.3

These images illustrate graphically and dramatically the potential bony lytic effects of multiple myeloma which may not be detected on routine radiography.