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23 year old male, neck pain Findings? DDx?
Bone Scan Findings? Dose this narrow your DDx?

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Pelvis Film Findings? Consistent with Previous studies?
Final images– “classic” Final Dx?

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Multiple Myeloma
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Initial neck radiograph showed 1 too many spinous processes; the corresponding vertebral body has collapsed = vertebra plana

General DDx for Vertebra plana: “MELT” Myeloma / Metastases; EG* / Ewings; Lymphoma / Leukemia; Trauma / TB
The cold lesion on bone scan is most consistent with myeloma, and this is borne out by the expansile pelvic lesion & lytic lesions shown
Myeloma Information
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*Multiple Myeloma is the most common primary malignant neoplasm in adults; usually 5th to 8th decade, with 98% >40 year old
*Symptoms include bone pain, anemia, RBC roleau formation, renal insufficiency, hypercalcemia, proteinuria, monoclona gammopathy (see serum protein electrophoresis image above)
*Radiological findings – endosteal scalloping / “punched-out” lesions; expansile osteolytic lesions (ribs, pelvic); diffuse osteopenia (in 15%); sclerotic form (in 1-3%, associated with POEMS syndrome) *Primary DDx: Mets, Amyloidosis, Myeloid Metaplasia *Prognosis: 20% 5-year survival
Similar finding, Different patient
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Above image show a more “classic” appearance for a vertebra plana
Alternative pnemonic: “FETISH” Fracture, EG, Tumor (myeloma, lymphoma, leukemia), Infection, Steroids, Hemangioma

These signals are relayed buying clomid online safe which then is by a number of such as medial preoptic and paraventricular nulcei.