title: Beyond the CRAB symptoms: a study of presenting clinical manifestations of multiple myeloma.
abstract: BACKGROUND
  Although the typical clinical manifestations of multiple myeloma (MM) are summarized by the CRAB symptoms (hypercalcemia, renal insufficiency, anemia, and bone lesions), a significant proportion of patients with MM present with a variety of other clinical manifestations. We conducted a study evaluating the presenting symptoms that led to the diagnosis of MM.
  
  
  METHODS
  We conducted a retrospective review of 170 consecutive patients with MM seen at the Penn State Hershey Cancer Institute.
  
  
  RESULTS
  Among patients with symptomatic MM, 74% presented with CRAB symptoms, 20% presented with non-CRAB manifestations, and 6% had both clinical features. Ten categories of non-CRAB manifestations were found, in order of decreasing frequency: neuropathy (because of spinal cord compression, nerve root compression, or peripheral neuropathy), extramedullary involvement, hyperviscosity syndrome, concomitant amyloidosis (eg, nephrotic syndrome or cardiopathy), hemorrhage/coagulopathy, systemic symptoms (eg, fever or weight loss), primary plasma cell leukemia, infections, cryoglobulinemia, and secondary gout. Kaplan-Meier estimates of survival in patients with non-CRAB manifestations did not show a significant difference from the survival of patients presenting with CRAB symptoms.
  
  
  CONCLUSIONS
  Presenting symptoms of MM may be grouped in a total of 14 categories, 4 for the CRAB and 10 for the less common non-CRAB features. Grouped together, non-CRAB manifestations do not appear to confer a negative effect on the prognosis of patients with MM.
authors.affiliation: Penn State Hershey Cancer Institute, 500 University Drive, Hershey, PA 17033, USA. gtalamo@hmc.psu.edu
authors.forename: Giampaolo
authors.initials: G
authors.lastname: Talamo
authors.forename: Umar
authors.initials: U
authors.lastname: Farooq
authors.forename: Maurizio
authors.initials: M
authors.lastname: Zangari
authors.forename: Jason
authors.initials: J
authors.lastname: Liao
authors.forename: Nathan G
authors.initials: NG
authors.lastname: Dolloff
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Loughran
authors.forename: Elliot
authors.initials: E
authors.lastname: Epner
mesh_terms: D000015:Abnormalities, Multiple / Q000145:classification / Q000473:pathology; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000740:Anemia / Q000473:pathology*; D001842:Bone and Bones / Q000473:pathology*; D003937:Diagnosis, Differential; D005260:Female; D005269:Femur; D005500:Follow-Up Studies; D006801:Humans; D006934:Hypercalcemia / Q000473:pathology*; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009101:Multiple Myeloma / Q000175:diagnosis*; D011379:Prognosis; D051437:Renal Insufficiency / Q000473:pathology*; D012189:Retrospective Studies; D013577:Syndrome