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Lu C, He D, Wang R, Mou H, Bi G, Liu C, Zhou G, Bao P. Elevated polyclonal IgG4 mimicking a monoclonal gammopathy in IgG4-related disease-a case-based review. Clin Rheumatol 2024; 43:3019-3028. [PMID: 38990379 DOI: 10.1007/s10067-024-07062-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/29/2024] [Accepted: 07/04/2024] [Indexed: 07/12/2024]
Abstract
IgG4-related diseases (IgG-RDs) are a group of fibroinflammatory diseases that affect a variety of tissues, resulting in tumour-like effects and/or organ dysfunction. Monoclonal gammopathies (MGPs) are a group of disorders characterized by clonal proliferation of plasma cells or lymphoid cells resulting in the secretion of a monoclonal immunoglobulin. Cases of MGPs in IgG4-RDs coexisting with plasma cell dyscrasias and lymphoid neoplasms have been reported over the past few years. Therefore, the results of examinations of M protein in IgG4-RD patients should be interpreted with caution. Herein, we report the case of a 58-year-old male with a history of type 2 diabetes who presented with submandibular masses, anosmia, swollen lymph nodes, proteinuria, and renal impairment. Laboratory tests revealed hyperglobulinemia and elevated levels of IgG4 (124 g/L) and serum-free light chains (sFLCs). Serum protein electrophoresis (SPEP) revealed an M spike of 5.6 g/dL, and immunofixation electrophoresis (IPE) revealed biclonal IgG-κ and IgG-λ. The patient underwent bone marrow, lymph node, and kidney biopsy, which ruled out plasma cell disorders and lymphoma. He was finally diagnosed with an IgG4-RD comorbid with diabetic nephropathy. The findings in this case highlight that significant activation of B cells in IgG4-RD patients, especially those with multiorgan involvement can lead to significant hyperglobulinemia and high sFLC and IgG4 levels, which are more pronounced in the setting of renal impairment. Relatively high concentrations of polyclonal IgG4 can give rise to a focal band bridging the β and γ fractions, which may mimic the appearance of a monoclonal band on SPEP and monoclonal gammaglobulinemia in IFE. The patient experienced considerable improvement in his symptoms after rituximab combined with glucocorticoid therapy, and a monoclonal immunoglobulin was not detected.
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Affiliation(s)
- Chunlei Lu
- Nephrology Department, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, #98 Nantong West Road, Yangzhou, 225001, China
| | - Dafeng He
- Nephrology Department, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, #98 Nantong West Road, Yangzhou, 225001, China
| | - Rong Wang
- Nephrology Department, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, #98 Nantong West Road, Yangzhou, 225001, China
| | - Hongbin Mou
- Nephrology Department, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, #98 Nantong West Road, Yangzhou, 225001, China
| | - Guangyu Bi
- Nephrology Department, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, #98 Nantong West Road, Yangzhou, 225001, China
| | - Changhua Liu
- Nephrology Department, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, #98 Nantong West Road, Yangzhou, 225001, China
| | - Gang Zhou
- Nephrology Department, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, #98 Nantong West Road, Yangzhou, 225001, China.
| | - Ping Bao
- Functional Examination Room, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, #98 Nantong West Road, Yangzhou, 225001, China.
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Lin CC, Lee HL, Chuo HY, Chen TA, Liu MY, Chen LM. Plasmacytosis mimicking multiple myeloma in angioimmunoblastic T-cell lymphoma: A case report and review of literature. World J Clin Cases 2024; 12:3226-3234. [PMID: 38898855 PMCID: PMC11185400 DOI: 10.12998/wjcc.v12.i17.3226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/18/2024] [Accepted: 04/23/2024] [Indexed: 06/04/2024] Open
Abstract
BACKGROUND Angioimmunoblastic T-cell lymphoma (AITL) is a common subtype of peripheral T-cell lymphoma. Approximately half of patients with AITL may concurrently present with hypergammaglobulinemia. Increased numbers of plasma cells in the bone marrow are commonly observed at diagnosis. These tumors mimic plasma cell myelomas, hindering a conundrum of clinical diagnoses and potentially delaying appropriate treatment. CASE SUMMARY A 78-year-old woman experienced poor appetite, weight loss of 5 kg, fatigue 2 months before presentation, and shortness of breath 2 d before presentation, but no fever or night sweats. Physical examination revealed splenomegaly and many palpable masses over the bilateral axillary regions, approximately > 2 cm in size, with rubbery consistency and no tenderness. Blood tests revealed anemia and thrombocytopenia, lactate dehydrogenase level of 153 U/L, total protein level of 10.9 g/dL, albumin to globulin ratio of 0.2, and immunoglobulin G level more than the upper limit of 3000 mg/dL. The free kappa and lambda light chain concentrations were 451 and 614 mg/L, respectively. A pathological examination confirmed the diagnosis of AITL. The initial treatment was the cyclophosphamide, epirubicin, vincristine, and prednisolone regimen. Following this treatment, pleural effusion was controlled, and the patient was discharged in a stable condition and followed up in our outpatient department. CONCLUSION This report highlights the importance of differentiating reactive plasmacytosis from plasma cell myeloma in patients with hypergammaglobulinemia. A precise diagnosis of AITL requires a comprehensive evaluation, involving clinical, immunophenotypic, and histological findings conducted by a multidisciplinary team to ensure appropriate treatment.
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Affiliation(s)
- Chia-Ching Lin
- Division of Cardiovascular Surgery, Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung 802, Taiwan
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Hsu-Lin Lee
- Division of Hematology and Oncology, Department of Internal Medicine, Taichung Armed Forces General Hospital, Taichung 411, Taiwan
- Division of Hematology and Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Hsin-Yi Chuo
- Department of Internal Medicine, Taichung Armed-Forces General Hospital, Taichung 411, Taiwan
| | - Tuo-An Chen
- Department of Pathology, Taichung Armed-Forces General Hospital, Taichung 411, Taiwan
| | - Ming-Yueh Liu
- Department of Radiation Oncology, Taichung Armed-Forces General Hospital, Taichung 411, Taiwan
- Department of Radiation Oncology, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Li-Mien Chen
- Division of Hematology and Oncology, Department of Internal Medicine, Taichung Armed Forces General Hospital, Taichung 411, Taiwan
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Lim SM, Wijeratne N, Choy KW, Nguyen TTH, Setiawan L, Loh TP. A review of clinical guidelines, laboratory recommendations and external quality assurance programs for monoclonal gammopathy testing. Crit Rev Clin Lab Sci 2024; 61:107-126. [PMID: 37776896 DOI: 10.1080/10408363.2023.2257306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/06/2023] [Indexed: 10/02/2023]
Abstract
Monoclonal gammopathy (MG) is a spectrum of diseases ranging from the benign asymptomatic monoclonal gammopathy of undetermined significance to the malignant multiple myeloma. Clinical guidelines and laboratory recommendations have been developed to inform best practices in the diagnosis, monitoring, and management of MG. In this review, the pathophysiology, relevant laboratory testing recommended in clinical practice guidelines and laboratory recommendations related to MG testing and reporting are examined. The clinical guidelines recommend serum protein electrophoresis, serum immunofixation and serum free light chain measurement as initial screening. The laboratory recommendations omit serum immunofixation as it offers limited additional diagnostic value. The laboratory recommendations offer guidance on reporting findings beyond monoclonal protein, which was not required by the clinical guidelines. The clinical guidelines suggested monitoring total IgA concentration by turbidimetry or nephelometry method if the monoclonal protein migrates in the non-gamma region, whereas the laboratory recommendations make allowance for involved IgM and IgG. Additionally, several external quality assurance programs for MG protein electrophoresis and free light chain testing are also appraised. The external quality assurance programs show varied assessment criteria for protein electrophoresis reporting and unit of measurement. There is also significant disparity in reported monoclonal protein concentrations with wide inter-method analytical variation noted for both monoclonal protein quantification and serum free light chain measurement, however this variation appears smaller when the same method was used. Greater harmonization among laboratory recommendations and reporting format may improve clinical interpretation of MG testing.
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Affiliation(s)
| | - Nilika Wijeratne
- Dorevitch Pathology, Melbourne, Australia
- School of Clinical Sciences at Monash Health, Department of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
- Eastern Health Pathology, Eastern Health, Box Hill, Australia
- Dorevitch Pathology, Heidelberg, Australia
| | | | | | - Lyana Setiawan
- Dharmais Hospital National Cancer Centre, West Jakarta, Indonesia
| | - Tze Ping Loh
- National University Hospital, Singapore, Singapore
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Chong YP, Lim SM, Loh TP, Mollee P, Wijeratne N, Choy KW. Screening for and diagnosis of monoclonal gammopathy. J Clin Pathol 2023; 76:727-733. [PMID: 37604683 DOI: 10.1136/jcp-2023-208774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/03/2023] [Indexed: 08/23/2023]
Abstract
Monoclonal gammopathy is a spectrum of disorders characterised by clonal proliferation of plasma cells or lymphocytes, which produce abnormal immunoglobulin or its components (monoclonal proteins). Monoclonal gammopathies are often categorised as low-tumour-burden diseases (eg, amyloid light chain (AL) amyloidosis), premalignant disorders (such as monoclonal gammopathy of undetermined significance and smouldering multiple myeloma), and malignancies (eg, multiple myeloma and Waldenström's macroglobulinaemia). Such diversity of concentration and structure makes monoclonal protein a challenging clonal marker. This article provides an overview on initial laboratory testing of monoclonal gammopathy to guide clinicians and laboratory professionals in the selection and interpretation of appropriate investigations.
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Affiliation(s)
- Yuh Ping Chong
- School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia
| | - Say Min Lim
- Department of Pathology, Hospital Teluk Intan, Teluk Intan, Malaysia
| | - Tze Ping Loh
- Department of Laboratory Medicine, National University Hospital, Singapore
| | - Peter Mollee
- Pathology Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Nilika Wijeratne
- Dorevitch Pathology, Heidelberg, Victoria, Australia
- School of Clinical Sciences at Monash Health, Department of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
- Eastern Health Pathology, Eastern Health, Box Hill, Victoria, Australia
| | - Kay Weng Choy
- Department of Pathology, Northern Health, Epping, Victoria, Australia
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A lesson learnt from laboratory error: isoelectric focusing improves the accuracy in interpreting polyclonal or monoclonal IgG4. Pathology 2023; 55:402-405. [PMID: 36002359 DOI: 10.1016/j.pathol.2022.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/16/2022] [Accepted: 05/22/2022] [Indexed: 11/24/2022]
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Proceedings of the Australasian Association of Clinical Biochemistry and Laboratory Medicine's 2021 Virtual Scientific Conference. Clin Biochem Rev 2021; 42:S1-S36. [PMID: 35719697 PMCID: PMC9199447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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Zhao EJ, Cheng CV, Mattman A, Chen LYC. Polyclonal hypergammaglobulinaemia: assessment, clinical interpretation, and management. LANCET HAEMATOLOGY 2021; 8:e365-e375. [PMID: 33894171 DOI: 10.1016/s2352-3026(21)00056-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 12/13/2022]
Abstract
This Review outlines a practical approach to assessing and managing polyclonal hypergammaglobulinaemia in adults. Polyclonal hypergammaglobulinaemia is most commonly caused by liver disease, immune dysregulation, or inflammation, but can also provide an important diagnostic clue of rare diseases such as histiocyte disorders, autoimmune lymphoproliferative syndrome, Castleman disease, and IgG4-related disease. Causes of polyclonal hypergammaglobulinaemia can be divided into eight categories: liver disease, autoimmune disease and vasculitis, infection and inflammation, non-haematological malignancy, haematological disorders, IgG4-related disease, immunodeficiency syndromes, and iatrogenic (from immunoglobulin therapy). Measuring serum concentrations of C-reactive protein and IgG subclasses are helpful in diagnosis. IL-6-mediated inflammation, associated with persistently elevated C-reactive protein concentrations (≥30 mg/L), is an important driver of polyclonal hypergammaglobulinaemia in some cases. Although the presence of markedly elevated serum IgG4 concentrations (>5 g/L) is around 90% specific for diagnosing IgG4-related disease, mildly elevated serum IgG4 concentrations are seen in many conditions. In most cases, managing polyclonal hypergammaglobulinaemia simply involves treating the underlying condition. Rarely, however, polyclonal hypergammaglobulinaemia can lead to hyperviscosity, requiring plasmapheresis.
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Affiliation(s)
- Eric J Zhao
- Division of Hematology, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, Vancouver General Hospital, Vancouver, BC, Canada
| | - Catherine V Cheng
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, Vancouver General Hospital, Vancouver, BC, Canada
| | - Andre Mattman
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, Vancouver General Hospital, Vancouver, BC, Canada; Department of Pathology and Laboratory Medicine, St Paul's Hospital, Vancouver, BC, Canada
| | - Luke Y C Chen
- Division of Hematology, University of British Columbia, Vancouver, BC, Canada; Centre for Health Education Scholarship, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, Vancouver General Hospital, Vancouver, BC, Canada.
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Grady JL, Avery A, Moore AR, Harris LJ, Kakar N, Rout ED. Progressive gammopathy and coagulopathy in a young English bulldog. THE CANADIAN VETERINARY JOURNAL = LA REVUE VETERINAIRE CANADIENNE 2021; 62:160-166. [PMID: 33542555 PMCID: PMC7808204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
A restricted polyclonal or biclonal gammopathy resulting in bleeding tendencies was diagnosed in a young, neutered male English bulldog with concurrent splenomegaly, anemia, and severe elevations in IgM and, to a lesser degree, IgA immunoglobulins. There was a positive clinical response to treatment with prednisone and chlorambucil. This case bears similarity to a recently published syndrome of polyclonal gammopathy that is not neoplastic in origin in this breed. Key clinical message: The current case describes the management and clinical course of a recently described syndrome of polyclonal gammopathy in English bulldogs.
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Affiliation(s)
- Jennifer L Grady
- Tufts University, Cummings School of Veterinary Medicine, Department of Clinical Sciences, 200 Westboro Road, North Grafton, Massachusetts 01536, USA (Grady, Kakar); Colorado State University, College of Veterinary Medicine and Biomedical Science, Department of Microbiology, Immunology, and Pathology, 200 West Lake Street, Fort Collins, Colorado 80523 USA (Avery, Moore, Harris, Rout)
| | - Anne Avery
- Tufts University, Cummings School of Veterinary Medicine, Department of Clinical Sciences, 200 Westboro Road, North Grafton, Massachusetts 01536, USA (Grady, Kakar); Colorado State University, College of Veterinary Medicine and Biomedical Science, Department of Microbiology, Immunology, and Pathology, 200 West Lake Street, Fort Collins, Colorado 80523 USA (Avery, Moore, Harris, Rout)
| | - A Russell Moore
- Tufts University, Cummings School of Veterinary Medicine, Department of Clinical Sciences, 200 Westboro Road, North Grafton, Massachusetts 01536, USA (Grady, Kakar); Colorado State University, College of Veterinary Medicine and Biomedical Science, Department of Microbiology, Immunology, and Pathology, 200 West Lake Street, Fort Collins, Colorado 80523 USA (Avery, Moore, Harris, Rout)
| | - Lauren J Harris
- Tufts University, Cummings School of Veterinary Medicine, Department of Clinical Sciences, 200 Westboro Road, North Grafton, Massachusetts 01536, USA (Grady, Kakar); Colorado State University, College of Veterinary Medicine and Biomedical Science, Department of Microbiology, Immunology, and Pathology, 200 West Lake Street, Fort Collins, Colorado 80523 USA (Avery, Moore, Harris, Rout)
| | - Neketa Kakar
- Tufts University, Cummings School of Veterinary Medicine, Department of Clinical Sciences, 200 Westboro Road, North Grafton, Massachusetts 01536, USA (Grady, Kakar); Colorado State University, College of Veterinary Medicine and Biomedical Science, Department of Microbiology, Immunology, and Pathology, 200 West Lake Street, Fort Collins, Colorado 80523 USA (Avery, Moore, Harris, Rout)
| | - Emily D Rout
- Tufts University, Cummings School of Veterinary Medicine, Department of Clinical Sciences, 200 Westboro Road, North Grafton, Massachusetts 01536, USA (Grady, Kakar); Colorado State University, College of Veterinary Medicine and Biomedical Science, Department of Microbiology, Immunology, and Pathology, 200 West Lake Street, Fort Collins, Colorado 80523 USA (Avery, Moore, Harris, Rout)
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9
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Rade A, Đuras A, Kocijan I, Banković Radovanović P, Turčić A. Simple thrombin-based method for eliminating fibrinogen interference in serum protein electrophoresis of haemodialysed patients. Biochem Med (Zagreb) 2020; 30:020705. [PMID: 32292283 PMCID: PMC7138005 DOI: 10.11613/bm.2020.020705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 02/21/2020] [Indexed: 11/10/2022] Open
Abstract
Introduction Serum samples of haemodialysed patients collected through vascular access devices, e.g. central venous catheter (CVC) can contain residual heparin, which can cause incomplete clotting and consequently fibrinogen interference in serum protein electrophoresis (SPE). We hypothesized that this problem may be overcome by addition of thrombin and aimed to find a simple thrombin-based method for fibrinogen interference removal. Materials and methods Blood samples of 51 haemodialysed patients with CVC were drawn through catheter into Clot Activator Tube (CAT) and Rapid Serum Tube Thrombin (RST) vacutainers (Becton Dickinson, New Jersey, USA) following the routine hospital protocols and analysed with gel-electrophoresis (Sebia, Lisses, France). Samples were redrawn in the CAT tubes and re-analysed after being treated with thrombin using two methods: transferring CAT serum into RST vacutainer and treatment of CAT serum with fibrinogen reagent (Multifibren U, Siemens, Marburg, Germany). Results Direct blood collection in RST proved to be slightly more efficient than CAT in removing the interfering band in beta fraction (CAT removed 6/51 and RST removed 12/51, P = 0.031). Transferring CAT serum into the RST vacutainer proved to be more efficient for subsequent removal of interfering band from CAT serum than the addition of fibrinogen reagent (39/45 vs. 0/45 samples with efficiently removed interfering band, P < 0.001). Conclusion Fibrinogen interference caused by incomplete clotting because of residual heparin can be overcome by addition of thrombin. Transferring CAT serum into the RST vacutainer was the most efficient method.
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Affiliation(s)
- Anamarija Rade
- Medical biochemistry laboratory, General Hospital Varaždin, Varaždin, Croatia
| | - Anamarija Đuras
- Medical biochemistry laboratory, General Hospital Varaždin, Varaždin, Croatia
| | - Irena Kocijan
- Medical biochemistry laboratory, General Hospital Varaždin, Varaždin, Croatia
| | | | - Ana Turčić
- Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia
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10
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Clinical utility of serum IgG4 measurement. Clin Chim Acta 2020; 506:228-235. [PMID: 32272158 DOI: 10.1016/j.cca.2020.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/01/2020] [Accepted: 04/01/2020] [Indexed: 12/12/2022]
Abstract
This article will review the structure and function of IgG4, methods of measuring serum IgG4 concentrations, clinical conditions associated with increased and decreased serum IgG4, and the test characteristics of serum IgG4 in the diagnosis and management of Immunoglobulin G4-Related Disease (IgG4-RD). The four subclasses of IgG were discovered in 1964 through experiments on monoclonal IgG in patients with myeloma. Since 2001, interest in measuring serum IgG subclasses has increased dramatically due to the emergence of IgG4-RD, a multisystem fibroinflammatory condition wherein polyclonal serum IgG4 concentration is increased in approximately 70% of cases. Increased serum IgG4 typically manifests as a restriction in the anodal gamma region on serum protein electrophoresis, often with beta-gamma bridging, and can be mistaken as a monoclonal protein or polyclonal increase in IgA. Limitations of current clinical methods used in quantitation of serum IgG4 concentrations will be discussed, including the common immunonephelometric assays and LC-MS/MS based assays. Polyclonal IgG4 elevation is not specific for IgG4-RD, and may also occur in conditions such as eosinophilic granulomatosis with polyangiitis (EGPA), lymphoma, and multicentric Castleman disease (MCD). Race and gender differences also affect interpretation of serum IgG4 concentrations, for instance Asians have a higher serum IgG4 concentration than Whites and males have a higher concentration than females.
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Liu H, Wang G, Song J, Guan J, Shao Z, Fu R. Pseudo-monoclonal gammopathy due to autoimmune disease: a case report. J Int Med Res 2019; 48:300060519866618. [PMID: 31550956 PMCID: PMC7607182 DOI: 10.1177/0300060519866618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Hyperglobulinemia is a common manifestation of plasma cell disease, and it is sometimes
caused by autoimmune diseases (AIDs). We report an uncommon presentation of
hyperglobulinemia, with a high amount of plasma cells in bone marrow, pancytopenia,
hematemesis, and splenomegaly in an 18-year-old woman. Some examinations were performed to
determine the diagnosis, including serum protein electrophoresis, immunofixation
electrophoresis, the free light chain assay, abdominal enhanced computed tomography (CT)
and CT venography, and positron-emission tomography-CT. The patient was finally diagnosed
with AID. Considerable improvement in her symptoms was observed after immunosuppressive
therapy. Findings in this case highlight that not only differentiation of
hyperglobulinemia caused by monoclonal or polyclonal immunoglobulin, but also AIDs, need
to be considered to exclude non-Hodgkin’s lymphoma and plasma cell disease.
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Affiliation(s)
- Hui Liu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Guojin Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Jia Song
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Jing Guan
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Zonghong Shao
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Rong Fu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
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Sepiashvili L, Kohlhagen MC, Snyder MR, Willrich MAV, Mills JR, Dispenzieri A, Murray DL. Direct Detection of Monoclonal Free Light Chains in Serum by Use of Immunoenrichment-Coupled MALDI-TOF Mass Spectrometry. Clin Chem 2019; 65:1015-1022. [DOI: 10.1373/clinchem.2018.299461] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 04/24/2019] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
Free light chain (FLC) quantification is the most analytically sensitive blood-based method commercially available to diagnose and monitor patients with plasma cell disorders (PCDs). However, instead of directly detecting monoclonal FLCs (mFLCs), FLC assays indirectly assess clonality based on quantifying κ and λ FLCs and determination of the к/λ FLC ratio. Often an abnormal FLC ratio is the only indication of a PCD, and confirmation by a direct method increases diagnostic confidence. The aim of this study was to develop an analytically sensitive method for direct detection of mFLCs.
METHODS
Patient sera (n = 167) previously assessed by nephelometric FLC quantification and immunofixation electrophoresis (IFE) were affinity enriched for IgG, IgA, and total and free κ and λ light chains and subjected to MALDI-TOF MS. Relative analytical sensitivity of these methods was determined using serially diluted sera containing mFLCs.
RESULTS
In sera with abnormal FLC ratios (n = 127), 43% of monoclonal proteins were confirmed by IFE, 57% by MALDI-TOF MS without FLC enrichment, and 87% with FLC enrichment MALDI-TOF MS. In sera with normal FLC ratios (n = 40), the FLC MALDI-TOF MS method identified 1 patient with an mFLC. Serial dilution and analysis of mFLC containing sera by IFE, nephelometry, and FLC MALDI-TOF MS demonstrated that FLC MALDI-TOF MS analysis had the highest analytical sensitivity.
CONCLUSIONS
FLC immunoenrichment coupled to MALDI-TOF MS enables direct detection of mFLCs and significantly increases the confirmation of abnormal serum FLC ratios over IFE and MALDI-TOF MS without FLC enrichment, thereby providing added confidence for diagnosing FLC PCDs.
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Affiliation(s)
- Lusia Sepiashvili
- Department of Pediatric Laboratory Medicine, The Hospital for Sick Children/Research Institute, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, ON, Canada
| | - Mindy C Kohlhagen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Melissa R Snyder
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Maria A V Willrich
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Angela Dispenzieri
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
- Department of Hematology, Mayo Clinic, Rochester, MN
| | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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13
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Chen LYC, Mattman A, Seidman MA, Carruthers MN. IgG4-related disease: what a hematologist needs to know. Haematologica 2019; 104:444-455. [PMID: 30705099 PMCID: PMC6395313 DOI: 10.3324/haematol.2018.205526] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 01/07/2019] [Indexed: 12/14/2022] Open
Abstract
IgG4-related disease is a fibro-inflammatory condition that can affect nearly any organ system. Common presentations include major salivary and lacrimal gland enlargement, orbital disease, autoimmune pancreatitis, retroperitoneal fibrosis and tubulointerstitial nephritis. This review focuses on the hematologic manifestations of IgG4-related disease, including lymphadenopathy, eosinophilia, and polyclonal hypergammaglobulinemia. The disease can easily be missed by unsuspecting hematologists, as patients may present with clinical problems that mimic disorders such as multicentric Castleman disease, lymphoma, plasma cell neoplasms and hypereosinophilic syndromes. When IgG4-related disease is suspected, serum protein electrophoresis and IgG subclasses are helpful as initial tests but a firm histological diagnosis is essential both to confirm the diagnosis and to rule out mimickers. The central histopathological features are a dense, polyclonal, lymphoplasmacytic infiltrate enriched with IgG4-positive plasma cells (with an IgG4/IgG ratio >40%), storiform fibrosis, and obliterative phlebitis. Importantly for hematologists, the latter two features are seen in all tissues except bone marrow and lymph nodes, making these two sites suboptimal for histological confirmation. Many patients follow an indolent course and respond well to treatment, but a significant proportion may have highly morbid or fatal complications such as periaortitis, severe retroperitoneal fibrosis or pachymeningitis. Corticosteroids are effective but cause new or worsening diabetes in about 40% of patients. Initial response rates to rituximab are high but durable remissions are rare. More intensive lymphoma chemotherapy regimens may be required in rare cases of severe, refractory disease, and targeted therapy against plasmablasts, IgE and other disease biomarkers warrant further exploration.
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Affiliation(s)
- Luke Y C Chen
- Division of Hematology, Department of Medicine, University of British Columbia
| | - Andre Mattman
- Department of Pathology and Laboratory Medicine, St. Paul's Hospital
| | - Michael A Seidman
- Department of Pathology and Laboratory Medicine, St. Paul's Hospital
- Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mollie N Carruthers
- Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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