Clinical presentation

A 61-year-old man presented with a 4-week history of rectal bleeding, constipation, bloating, abdominal distension and low back pain. His bowels had not opened for 4 days prior to admission. Physical examination revealed a distended, tympanic abdomen. Routine laboratory tests confirmed renal failure (urea 13 mmol/l, creatinine 200 μmol/l), hypercalcaemia (3.7 mmol/l), albumin 32 g/l and C-reactive protein (CRP) 25 mg/l. Parathormone was suppressed (7 pg/l (15–65)). Abdominal x-ray suggested an ileus. CT abdomen revealed mural thickening of the left hemi-colon along with collapse of the third lumbar vertebra. An isotope bone scan was unremarkable, while MRI of the spine confirmed the presence of multiple lytic lesions. Immunoglobulin G (IgG) was 27.39 g/l (6.0–16.0) and electrophoresis …