Shoulder pad sign and asymptomatic hypercalcemia in a patient with end-stage kidney disease

Interpreting an abnormal serum calcium level in subjects with chronic kidney disease (CKD) requires the simultaneous evaluation of various clinical and laboratory parameters. An excessive intake of calcium salts and vitamin D overdosing may be the most common etiologies of hypercalcemia in individuals with advanced CKD. Nevertheless, it should be noted that such patients are susceptible to all diseases that may cause hypercalcemia in subjects without renal disease. In this report, we describe the case of a male chronic hemodialysis patient who developed asymptomatic hypercalcemia associated with polyarticular swelling. On the basis of the findings of systemic workup, he was finally diagnosed as having multiple myeloma. The so-called shoulder pad sign, which is pathognomonic for light chain amyloidosis, although its detection remains a challenge for physicians, was a clue leading to the prompt diagnosis of the disease in the current case. The impact of articular manifestations on the diagnostic strategy for assessing multiple myeloma is also discussed.