Hidden in Plain Sight: Accelerating Multiple Myeloma Diagnosis in Ambulatory Patients with Anemia

Document Type

Conference Proceeding - Restricted Access

Publication Date

5-8-2026

Abstract

Multiple myeloma (MM) is the second most common hematologic malignancy, yet due to variable clinical presentation most patients undergo many primary care visits (median 3) before they are referred to hematology. A delay in MM diagnosis is linked to shorter disease-free survival and more MM-related complications. Anemia is initially present in 73% of patients. Falsely attributing this chief complaint to another disease process can lead to non-hematology specialty referral, doubling the diagnostic interval (median 120 vs. 59 days). There is no direct data available on how unnecessary invasive testing influences MM diagnostic delays. Nevertheless, invasive GI work-up should not overshadow broader differential for anemia. As seen in this case, failing to obtain further noninvasive tests and to recognize MM red flags postponed the diagnosis until the onset of end-organ damage.

83 y.o. male with PMHx of type 2 diabetes, HTN, and CAD presented to primary care with 2 months of fatigue, weakness, decreased endurance, and shortness of breath. Blood work showed hemoglobin 8.8 g/dl, MCV 105.9 fl, eGFR 59 (reduced from previous), high normal Calcium 10.4mg/dl, normal B12 and folate levels, ferritin 740 ng/ml, low reticulocyte production index 0.9. Despite no evidence for iron deficiency anemia, EGD and colonoscopy were completed 1 month later with normal findings. Soon after endoscopies patient was admitted to hospital due to worsening fatigue, shortness of breath, and peripheral edema. He was found to have stage 3 AKI, nephrotic syndrome, progressively worsening anemia, and hypercalcemia. Chest imaging showed bilateral pleural effusions. Serum protein electrophoresis identified monoclonal kappa light chain, kappa/lambda FLC Ratio was 1078. Multiple rounded lucent bony pelvis lesions were identified on bone survey. Bone marrow biopsy confirmed Plasma Cell Myeloma.

This case illustrates that a delay in MM diagnosis is associated with higher incidence of complications. It highlights the importance of including MM in the differential for unexplained normocytic or macrocytic anemia. AGA only recommends bidirectional endoscopy for iron deficiency anemia, defined as ferritin < 45ng/ml. AAFP recommends early use of routine laboratory tests in the anemia work up, such as reticulocyte count index and BMP. This may help primary care providers identify MM earlier, bypassing unnecessary invasive procedures and accelerating treatment.

Comments

2026 Research Day Corewell Health West, Grand Rapids, MI, May 8, 2026. Abstract 1909

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