Intended for healthcare professionals

Endgames Spot Diagnosis

Abnormality on a skull radiograph

BMJ 2017; 356 doi: (Published 05 January 2017) Cite this as: BMJ 2017;356:i6315
  1. Janice Ser Huey Tan, core medical trainee year 2 doctor1,
  2. Timothy Shao Ern Tan, foundation year 1 doctor1
  1. 1Department of Medicine, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
  1. Correspondence to: T S E Tan timothy.tan.shao.ern{at}

A 65 year old woman presented with a four week history of increased fatigue, intermittent chest pain, dyspnoea, and frequent constipation. Biochemistry showed haemoglobin of 95 g/L (baseline 130 g/L) and an estimated glomerular filtration rate of 5 ml/min/1.73m2 (baseline 50 ml/min/1.73m2). Initial chest radiography revealed multiple unexplained rib fractures, which prompted a further skeletal survey, including a radiograph of the skull (fig 1).

Fig 1 Radiograph of the skull

What does the skull radiograph show?


Lytic bone lesions caused by myeloma bone disease (fig 2).


The skull radiograph (fig 2) shows widespread mottled lytic punched out deposits in the skull vault, which creates a “pepper pot” …

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