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Hypercalcaemia, Renal Dysfunction, Anaemia, Bone Disease (CRAB Criteria): A Case of Lymphoma
Balraj Singh1, Pooja Gogia2, Parminder Kaur3
1Hematology & Oncology Department, Saint Joseph's University Medical Center, Paterson, NJ, USA.
Insights
The CRAB criteria (hypercalcaemia, renal dysfunction, anaemia, bone disease) are typically associated with multiple myeloma. This case highlights that lymphoma can also present with CRAB criteria, emphasizing the need for broader differential diagnoses.
Area of Science:
- Oncology
- Hematology
- Internal Medicine
Background:
- The CRAB criteria (hypercalcaemia, renal dysfunction, anaemia, bone disease) are hallmarks of multiple myeloma (MM).
- These criteria signify end-organ damage and are crucial for MM diagnosis.
Purpose of the Study:
- To report a unique case where lymphoma mimicked multiple myeloma by presenting with all CRAB criteria.
- To underscore that CRAB criteria are not exclusive to multiple myeloma.
Main Methods:
- Case report of a 59-year-old patient presenting with symptoms consistent with CRAB criteria.
- Diagnostic work-up included imaging, laboratory tests for MM, and a pelvic mass biopsy.
- Exclusion of multiple myeloma through standard diagnostic procedures.
Main Results:
- The patient exhibited hypercalcaemia, kidney dysfunction, anaemia, and multiple osteolytic bone lesions.
- Initial investigations for multiple myeloma were negative.
- A pelvic mass biopsy confirmed diffuse large B-cell lymphoma.
Conclusions:
- The CRAB criteria are not pathognomonic for multiple myeloma.
- Lymphoma should be considered in the differential diagnosis for patients presenting with CRAB criteria.
- This case emphasizes the importance of comprehensive diagnostic evaluation beyond typical presentations.
Abstract:
Calcium elevation, Renal dysfunction, Anaemia and Bone disease (CRAB criteria) are usually seen in multiple myeloma (MM). We report a unique case of lymphoma with all the features of CRAB criteria. We describe a 59-year-old patient who presented with confusion, severe back pain, fatigue and constipation and was found to have hypercalcaemia, kidney dysfunction, anaemia and multiple osteolytic lesions. Physical examination and imaging did not reveal any enlarged lymph nodes. Work-up for MM (serum protein electrophoresis, serum immunofixation, bone marrow biopsy) was negative. The patient was diagnosed with diffuse large B-cell lymphoma based on a pelvic mass biopsy. Hence, our case report suggests that CRAB criteria are not pathognomonic of MM and that in the appropriate clinical scenario, lymphoma is a possible diagnosis.
Learning Points:
The CRAB criteria consist of end-organ damage with hypercalcaemia, renal dysfunction, anaemia and bone involvement.The CRAB criteria are not pathognomonic of multiple myeloma, and in the appropriate clinical scenario, lymphoma is a possible diagnosis.Major mechanisms by which hypercalcaemia of malignancy can occur are tumour secretion of parathyroid hormone-related protein (PTHrP), osteolytic metastases with local release of cytokines, or tumour production of 1,25-dihydroxyvitamin D (calcitriol).
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