Multiple myeloma is a malignant tumour of plasma cells infiltrating the bone marrow. The median age of presentation of myeloma is 65 years. A high index of suspicion is important for early recognition of the condition, especially to avoid renal failure from setting in as established renal failure can change the overall prognosis in myeloma patients.

This article gives a quick snapshot of when to suspect myeloma in primary care.

Red flag symptoms for diagnosis of myeloma in patients with back pain

  • Age >50 years
  • Pain that is worse in supine position
  • Pain that is worse at night or awakening from sleep
  • Pain with a band-like sensation around the body
  • Pain not responding to conventional analgesia
  • Associated constituitional symptoms (fever, weight loss, dehydration, recurrent infections)
  • New or worsening neurological deficits in lower limbs

Clinical manifestations of multiple myeloma


  • Back pain with red flags as above or bone pain over long bones/ribs
  • Constitutional symptoms like generalised malaise, lethargy or fever
  • Frequent infections without reason
  • Peripheral neuropathy/carpal tunnel syndrome
  • Unexplained bleeding
  • Symptoms of hypercalcaemia – Nausea, constipation, thirst
  • Symptoms of hyperviscosity – Headaches, easy bruising, epistaxis, ischaemic neurological symptoms

Clues from investigations:

  • Full blood count – Macrocytic anaemia, pancytopaenia, abnormal coagulation, rouleaux on blood film
  • Liver function tests – High total protein with low albumin
  • Urine – Proteinuria
  • High ESR
  • Bone profile – Hypercalcaemia
  • Renal profile – Renal dysfunction
  • Radiology – Lytic lesions in skull, vertebrae or long bones/vertebral compression fractures or just diffuse osteopaenia

Tests to send for diagnosing myeloma (in addition to the above-mentioned):

  • Serum protein electrophoresis and immunofixation
  • Serum free light chain assay

The SingHealth Duke-NUS Blood Cancer Centre (SDBCC) hosts specialty clinics for multiple myeloma, run by Haematologists specially trained to manage such patients. We often have clinical trials for patients with myeloma that help us to bring some of the most effective and newest discovered medicines against myeloma to our patients.

For more information on myeloma, please visit

GPs can call for appointments through the GP Appointment Hotlines at 6321 4402 (SGH) or 6436 8288 (NCCS).

By: Dr Chandramouli Nagarajan, Consultant, Department of Haematology, Singapore General Hospital; SingHealth Duke-NUS Blood Cancer Centre

Dr Chandramouli Nagarajan is a Consultant at the Department of Haematology, Singapore General Hospital (SGH) and the SingHealth Duke-NUS Blood Cancer Centre (SDBCC). He is a Clinical Lecturer at the NUS Yong Loo Lin School of Medicine and an Adjunct Assistant Professor at the Duke-NUS Medical School. He served as a Consultant Haematologist in the Northwest of England for 2½ years before joining SGH in 2014.

His main area of interest is malignant haematology, especially lymphomas, myeloma, as well as immune and laboratory haematology. His other area of interest is clinical/medical education and he has been involved in teaching undergraduate and postgraduate students throughout his career. He has contributed as a member of several committees, was the clinical lead for blood transfusion services and has been involved in research, serving as Principal Investigator in clinical trials, during his tenure in the United Kingdom.