Question

What is the likely diagnosis in a patient who has low back ache, L3 tenderness, and the following data: total proteins 8.9 g/dL, albumin:globulin ratio 2.9/5.9 (reversed), serum creatinine 5.5 mg/dL, TLC 4500/mm3, DLC neutrophils 55%, lymphocytes 40%, eosinophils 2%; blood urea was 93 mg/dL and serum creatinine was 1.2 mg/dL; ESR was 90 mm in the first hour?

• A. Waldenstrom's macroglobulinemia
• B. Multiple myeloma
• C. Amyloidosis
• D. Bone secondaries

Hint:

A reversed albumin to globulin ratio with a very high ESR and bone tenderness points to a plasma cell disorder with bone involvement.

Answer 1

The Correct Option is B

Step 1: Understanding the Question:
We need to fit a back pain patient with a set of lab clues to one diagnosis: raised total protein with a reversed albumin to globulin ratio, kidney impairment, a very high ESR, and vertebral tenderness.

Step 2: Key Concept:
A reversed albumin to globulin ratio, where globulin is higher than albumin, points to a large amount of abnormal protein (paraprotein) in the blood, usually made by a clone of plasma cells. A very high ESR happens because these abnormal proteins make red cells stick together and fall faster (rouleaux formation). Back pain with vertebral tenderness in this setting suggests bone involvement by the same disease process.

Step 3: Detailed Explanation:
Multiple myeloma fits every clue here: the plasma cell clone raises total globulin, flips the albumin to globulin ratio, drives the ESR to very high levels, damages the kidney through light chain deposits and cast formation (matching the raised creatinine), and causes lytic bone lesions that produce localized back pain and vertebral tenderness, which explains the L3 tenderness.
Waldenstrom's macroglobulinemia is also a clonal plasma-cell-related disorder, but it centers on IgM and typically causes hyperviscosity symptoms such as blurred vision and bleeding, with lytic bone lesions and vertebral tenderness being uncommon, so it fits this vignette poorly.
Amyloidosis can follow myeloma, but on its own it does not produce a sharply reversed albumin to globulin ratio from paraprotein overproduction, and vertebral tenderness is not its typical presentation.
Bone secondaries, meaning metastatic cancer in bone, cause bone pain but do not typically produce a reversed albumin to globulin ratio or such a striking rise in ESR, since there is no paraprotein being made.

Step 4: Final Answer:
The combination of reversed albumin to globulin ratio, very high ESR, renal impairment, and vertebral tenderness points to multiple myeloma.