Paraprotein screen in rheumatology — SCE Rheumatology MCQ

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HardMusculoskeletal InvestigationsParaprotein screen in rheumatologySCE Rheumatology

A 69-year-old man has shoulder and hip girdle pain labelled as PMR but responds poorly to prednisolone. ESR is 105 mm/hour, CRP is 12 mg/L, Hb is 92 g/L and calcium is 2.78 mmol/L. He reports night back pain. What is the most appropriate investigation?

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Correct answer: C — Serum protein electrophoresis and serum free light chains

Explanation lettering: D = shown as A · E = shown as B · A = shown as C · C = shown as D · B = shown as E

Serum protein electrophoresis and serum free light chains is best because anaemia, hypercalcaemia, high ESR with modest CRP and night back pain should prompt myeloma screening. B is less suitable because HLA-B27 assesses spondyloarthritis; C is less suitable because anti-Jo-1 assesses antisynthetase syndrome; D is less suitable because temporal ultrasound does not explain hypercalcaemia and anaemia; E is less suitable because escalating prednisolone risks delaying malignancy diagnosis. Clinical pearl: not every high ESR musculoskeletal presentation in older adults is PMR.

Reference: NICE myeloma guideline NG35; BSR PMR guideline