Multiple Myeloma: The Daily PANCE Blueprint
A 70-year-old man has back pain, anemia, a calcium of 11.8 mg/dL, a creatinine of 2.4 mg/dL, punched-out lytic bone lesions, and a monoclonal (M) spike on serum protein electrophoresis. Which peripheral blood smear finding is most characteristic?
A. Rouleaux formation
B. Auer rods
C. Smudge cells
D. Schistocytes
E. Heinz bodies
Answer and topic summary
The answer is A. Rouleaux formation.
The high level of circulating monoclonal immunoglobulin coats red cells and makes them stack like a roll of coins – rouleaux formation – which also raises the ESR and narrows the anion gap. Auer rods point to acute myeloid leukemia; smudge cells to chronic lymphocytic leukemia; schistocytes to microangiopathic hemolysis (TTP/HUS, DIC); and Heinz bodies to G6PD deficiency. Confirm with serum and urine protein electrophoresis and a marrow biopsy showing more than 10% clonal plasma cells.
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