Case Presentation:

A previously healthy 57‐year‐old African American man was admitted to the hospital with pain in the left hip and the epigastrium. He admitted to a 30‐pound weight loss over the preceding 6 months. Physical examination was notable for tenderness to palpation in the epigastric area. There was no rebound or guarding. The rest of the physical exam was unremarkable. Laboratory data revealed a hemoglobin of 8.2 g/dL, platelet count of 424,000/μL, WBC count of 13,800/μl, BUN of 32 mg/dL, creatinine of 3.2 mg/dL, serum calcium of 16.6 mg/dL, erythrocyte sedimentation rate of 101 mm/h, beta2‐microglobulin of 8.4 mg/dL, total protein of 5.4 g/dL, and albumin of 3.0 g/dL. HIV antibody and antinuclear antibodies (ANA) were negative. A skeletal survey was done as a part of hypercalcemia workup. This disclosed multiple lytic bone lesions. Serum protein electrophoresis did not reveal a monoclonal spike. Subsequently, bone marrow biopsy was performed, which was consistent with multiple myeloma. Nonsecretory multiple myeloma was thus diagnosed, and the patient was started on chemotherapy.


Multiple myeloma (MM) requires detection of monoclonal gammopathy in the serum or urine. Nonsecretory multiple myeloma (NSMM) is a rare variant of multiple myeloma (MM) that accounts for 1%‐5% of all cases. The clinical presentation and radiographic features of NSMM and classic MM are the same. However, NSMM does not exhibit monoclonal gammopathy, making the diagnosis difficult. In NSMM, the most common presenting clinical symptom is bone pain similar to our patient's pain, which was located in his left hip. Laboratory data may reveal anemia, hypercalcemia. and/ or renal insufficiency. In the presence of such clinical symptoms, it should be remembered that this rare variant must be considered despite absence of monoclonal spike on serunVurine protein electrophoresis. The therapeutic approach to MM and NSMM is the same, and long‐term outcome is similar.


We report this case to illustrate that excessive reliance on monoclonal gammopathy (M‐spike) to establish the diagnosis of MM can lead to missed or delayed diagnosis of nonsecretory multiple myeloma. Because hospitalists are the first to initiate such diagnostic workup, lack of awareness of this condition can result in increased morbidity and mortality

Author Disclosure:

K. Koduru, none; P. Koduru, none; T. Hamieh, none; G. Guron, none.