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Multiple Myeloma — MRCP Part 1 MCQ

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HardHaematologyMultiple MyelomaMRCP Part 1UKMLAPARA

A 64-year-old has back pain, normocytic anaemia, renal impairment and corrected calcium 3.0 mmol/L. Serum protein electrophoresis shows no discrete paraprotein, but serum free light-chain ratio is markedly abnormal and urine contains monoclonal free light chains. Which diagnosis remains most likely?

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Correct answer: D — Light-chain multiple myeloma despite absent serum M-protein

D is correct. Myeloma can produce only monoclonal free light chains, so the absence of a conventional serum M-protein does not exclude it. The combination of anaemia, kidney injury, hypercalcaemia, an abnormal free light-chain ratio and urinary monoclonal light chains is highly concerning for light-chain myeloma and warrants urgent haematology assessment with marrow and imaging evaluation. A, C and E do not explain monoclonal light chains plus marrow and renal features. B can cause hypercalcaemia but does not account for the monoclonal light-chain pattern.

Reference: NICE NG35: myeloma diagnosis and management: https://www.nice.org.uk/guidance/ng35/chapter/Recommendations GMC: PA registration assessment content map: https://www.gmc-uk.org/education/standards-guidance-and-curricula/standards-and-outcomes/pa-and-aa-prequalification-education-framework/pa-registration-assessment-content-map