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Scheid C, Landgren O. Early detection of multiple myeloma: A first step towards a screening programme. Br J Haematol 2024; 204:393-394. [PMID: 38168005 DOI: 10.1111/bjh.19274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 01/05/2024]
Abstract
Novel therapies for multiple myeloma have substantially improved the prognosis, but before patients are able to benefit from treatment, a diagnosis must have been made. The Myeloma UK laboratory working group has developed a three-part tool box to help primary care physicians to suspect myeloma despite mostly vague symptoms, to do the right tests and to derive the proper conclusions from the results. Commentary on: Drayson et al. Laboratory practice is central to earlier myeloma diagnosis; utilising a primary care diagnostic tool and laboratory guidelines integrated into haematology services. Br J Haematol 2024;204:476-486.
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Affiliation(s)
- Christof Scheid
- University Hospital and Center for Integrated Oncology Cologne, Cologne, Germany
| | - Ola Landgren
- Division of Myeloma, Sylvester Comprehensive Cancer Center, University of Miami, Coral Gables, Florida, USA
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2
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Banderker RB, Fazel FB, Zemlin AE, Khine AA, Jalavu TP. Serum-free light chain test utilisation at a South African academic laboratory and comparison with serum protein electrophoresis results. Afr J Lab Med 2023; 12:2201. [PMID: 38058849 PMCID: PMC10696567 DOI: 10.4102/ajlm.v12i1.2201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 09/05/2023] [Indexed: 12/08/2023] Open
Abstract
Background Serum protein electrophoresis (SPE), urine protein electrophoresis and immunofixation electrophoresis were traditionally utilised for the diagnosis of monoclonal gammopathies. The quantitative serum-free light chain (SFLC) assay is reportedly more sensitive and has been introduced to recent clinical guidelines. Objective This study aimed to investigate SFLC test utilisation and describe SPE findings in patients with abnormal SFLC ratios. Methods A retrospective audit of SFLC analyses was conducted in Cape Town, South Africa, from May 2018 to April 2020. Agreement between abnormal SFLC ratios and SPE results was determined in a sub-group of patients screened for monoclonal gammopathies. Serum-free light chains were analysed using Freelite® Kappa and Lambda assays. Results Of the 1425 patients included in the audit, 741 (52%) had abnormal SFLC ratios; 636 (45%) had increased and 105 (7%) had decreased SFLC ratios. In a sub-group analysis of 117 new patients with an abnormal SFLC ratio, 57 had a monoclonal protein (M-protein) on SPE (49%), and 60 (51%) did not. Four out of 60 patients without M-protein had a plasma cell dyscrasia, while renal impairment or inflammatory response accounted for the rest. Of the 57 patients with a M-protein and abnormal SFLC ratio, 41 (72%) had a plasma cell dyscrasia, seven (12%) had lymphomas and nine patients (16%) were unclassifiable. Conclusion Serum-free light chains should be requested when there is a high index of clinical suspicion. Neither SFLC nor SPE should be performed in isolation when screening patients for monoclonal gammopathy, to ensure that no patient is missed. What this study adds The study adds to the evidence on SFLC test utilisation. Serum protein electrophoresis alone may miss cases of light chain myeloma, while SFLC performed in isolation may produce false positive results in the setting of inflammatory disorders or renal impairment, leading to unnecessary further investigation.
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Affiliation(s)
- Razia B Banderker
- Department of Pathology, Division of Chemical Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Pathology, Division of Chemical Pathology, National Health Laboratory Service, Cape Town, South Africa
| | - Fatima B Fazel
- Department of Internal Medicine, Division of Clinical Haematology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Annalise E Zemlin
- Department of Pathology, Division of Chemical Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Pathology, Division of Chemical Pathology, National Health Laboratory Service, Cape Town, South Africa
| | - Aye-Aye Khine
- Division of Chemical Pathology, National Health Laboratory Service, Green Point, Cape Town, South Africa
| | - Thumeka P Jalavu
- Department of Pathology, Division of Chemical Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Pathology, Division of Chemical Pathology, National Health Laboratory Service, Cape Town, South Africa
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3
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Li B, Thompson S, Igot K, King R, Doogue M, Florkowski C. Artefactually low creatinine by Beckman Coulter enzymatic method due to immunoglobulin M paraprotein interference. Ann Clin Biochem 2023; 60:423-427. [PMID: 37482625 DOI: 10.1177/00045632231190507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
An 81-year-old man was admitted to hospital with symptomatic coronavirus disease (COVID-19) infection. He had a background of progressive chronic inflammatory demyelinating polyneuropathy associated with Waldenstrom's macroglobulinaemia. His plasma creatinine on four separate samples was inconceivably low (all ≤13 μmol/L), as measured by a Beckman Coulter enzymatic assay) after being 72 μmol/L 3 months earlier. On further investigation, his serum immunoglobulin M (IgM) was 15.4 g/L and his plasma creatinine measured by Roche enzymatic and Roche Jaffe methods was 62 μmol/L and 64 μmol/L, respectively. This was consistent with results post dilution studies and polyethylene glycol (PEG) precipitation on the Beckman Coulter assay. There was no evidence of similar interference when reviewing creatinine results from 10 other patients with IgM paraproteinaemia who had been tested in our laboratory. Clinicians and laboratorians are reminded that enzymatic creatinine is not free from interferences. IgM paraprotein negative interference of enzymatic creatinine is rare and specific to a patient's IgM and assay combination, but should be considered in patients with an unexplained low enzymatic creatinine result. Useful investigations to identify an interference include dilution studies, PEG precipitation and measuring creatinine on an alternative method such as Jaffe, mass spectrometry or an enzymatic method from a different platform.
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Affiliation(s)
- Bobby Li
- Te Whatu Ora - Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
- Biochemistry, Canterbury Health Laboratories, Christchurch, New Zealand
| | - Simon Thompson
- Te Whatu Ora - Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
- Biochemistry, Canterbury Health Laboratories, Christchurch, New Zealand
| | - Kareen Igot
- Te Whatu Ora - Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
- Biochemistry, Canterbury Health Laboratories, Christchurch, New Zealand
| | - Richard King
- Te Whatu Ora - Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
- Biochemistry, Canterbury Health Laboratories, Christchurch, New Zealand
| | - Matthew Doogue
- Te Whatu Ora - Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
- Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
| | - Chris Florkowski
- Te Whatu Ora - Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
- Biochemistry, Canterbury Health Laboratories, Christchurch, New Zealand
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4
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Bharati J, Shah N, Desai A, Gladstone D, Krushna Das C, Nieto MJ, Jhaveri KD, Izzedine H. Kidney and urinary tract involvement in systemic mastocytosis. Nephrol Dial Transplant 2023; 38:2456-2463. [PMID: 37113073 DOI: 10.1093/ndt/gfad081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Indexed: 04/29/2023] Open
Abstract
Systemic mastocytosis (SM) is a disorder of excessive mast cell accumulation in tissues due to a somatic gain-of-function mutation, commonly in the KIT gene, which prevents apoptosis of mast cells. Whereas bone marrow, skin, lymph nodes, spleen and gastrointestinal tract are commonly involved, kidneys are rarely involved directly by SM. However, there are increasing reports of indirect kidney involvement in patients with SM. Novel anti-neoplastic agents to treat advanced forms of SM include non-specific tyrosine kinase inhibitors, which are reported to be associated with kidney dysfunction in some patients. SM is also associated with immune-mediated glomerulonephritis (GN) such as mesangioproliferative GN, membranous nephropathy and diffuse proliferative GN. Kidney injury, in the form of monoclonal deposition disease and primary light chain amyloidosis, is reported in SM associated with plasma cell dyscrasia. In this narrative review we discuss the various ways kidneys (and the urinary tract) are involved in patients with SM.
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Affiliation(s)
- Joyita Bharati
- Division of Kidney Diseases and Hypertension, Glomerular Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | | | - Ankuri Desai
- Department of Dermatology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Douglas Gladstone
- Division of Hematology and Oncology, R J Zuckerberg Cancer Institute at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Chandan Krushna Das
- Department of Clinical Hematology and Medical Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Maria Jacqueline Nieto
- Division of Hematology and Oncology, R J Zuckerberg Cancer Institute at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Glomerular Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Hassan Izzedine
- Department of Nephrology, Peupliers Private Hospital, Paris, France
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Bender ST, Zeremski V, Wiech T, Mertens PR, Gross C. Case report: Acute kidney injury as the initial manifestation of chronic lymphocytic leukemia/small lymphocytic lymphoma. Front Med (Lausanne) 2023; 10:1279005. [PMID: 37928472 PMCID: PMC10622965 DOI: 10.3389/fmed.2023.1279005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 09/20/2023] [Indexed: 11/07/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is a lymphoproliferative disorder often diagnosed after incidental finding of leukocytosis. Renal involvement is usually clinically silent. Symptomatic renal impairment due to CLL/small lymphocytic lymphoma (SLL) cell infiltration in the kidney tissue is uncommon, and acute kidney injury (AKI) as a presenting feature is rare. In this case report, we describe the case of a patient with AKI caused by CLL/SLL infiltration as a presenting feature. Our report highlights the possibility of kidney injury as the first evident symptom of CLL/SLL. Kidney biopsy is the mainstay in these cases in order to establish a diagnosis. Treatment with zanubrutinib resulted in improved kidney function.
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Affiliation(s)
- Sascha T. Bender
- University Clinic for Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
| | - Vanja Zeremski
- University Hospital for Hematology and Oncology, Otto-von-Guericke University, Magdeburg, Germany
| | - Thorsten Wiech
- Institute for Pathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Peter R. Mertens
- University Clinic for Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
| | - Christian Gross
- University Clinic for Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg, Germany
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6
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Danalakshmi S. Monoclonal Light Chains with alpha 2 mobility on Serum Protein Electrophoresis. EJIFCC 2023; 34:250-257. [PMID: 37868083 PMCID: PMC10588080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Multiple myeloma (MM) is a neoplasm characterized by malignant proliferation of plasma cells that produce excessive quantities of a single type of immunoglobulin (Ig) called as monoclonal immunoglobulin or M-protein or paraprotein. M-protein produced can be either an intact antibody with both heavy and light-chain components or only light chains or rarely only heavy chains. Presence of M-protein in serum protein electrophoresis (PEP) is useful in the diagnosis, prognosis, and treatment of MM and other plasma cell dyscrasias. These M-proteins are identified commonly in beta and gamma regions and very rarely in alpha 2 region, appearing as a narrow band in agarose electrophoresis or as a sharp symmetric spike (M-spike) or peak in capillary zone electrophoresis. Here, we present an unusual case of monoclonal light chains producing two M- spikes in the alpha 2 globulin region in capillary zone electrophoresis.
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Affiliation(s)
- S. Danalakshmi
- Department of Biochemistry, Apollo hospitals, Chennai, Tamil Nadu, India
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7
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Khuong JN, Forsyth CJ, Manuel L, Kingsford-Smith K, Srivastava A, Bassin L. Paraprotein associated heparin resistance during cardiopulmonary bypass. Perfusion 2023; 38:1319-1321. [PMID: 35700111 DOI: 10.1177/02676591221109143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Heparin resistance during cardiopulmonary bypass poses a significant intraoperative dilemma. Antithrombin deficiency related heparin resistance is well described, but less common causes are still poorly understood and inadequately managed. CASE REPORT We present a case of heparin resistance during cardiopulmonary bypass in a gentleman with no previous haematological history or thrombotic risk factors. The patient required three times the regular dose of unfractionated heparin to achieve acceptable conditions to initiate and maintain bypass. The patient was found to have elevated serum immunoglobulin M (IgM) kappa paraprotein on post-operative investigation. DISCUSSION Paraproteins may exhibit non-specific binding to long polymeric chains of unfractionated heparin and inhibits the interaction between heparin and antithrombin. As a result, excessive doses of heparin are required to overcome this, which increases the risk of perioperative bleeding and other complications. CONCLUSION Elevated serum paraprotein levels should be recognised as a cause of heparin resistance during cardiopulmonary bypass.
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Affiliation(s)
- Jacqueline N Khuong
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Cecily J Forsyth
- Department of Medicine, Gosford Hospital, Gosford, NSW, Australia
| | - Lucy Manuel
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Kate Kingsford-Smith
- Perfusion and Autotransfusion Unit, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Arpit Srivastava
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Levi Bassin
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
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8
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Sloop GD, Moore C, Pop G, Weidman JJ, St Cyr JA. New Onset Anemia, Worsened Plasma Creatinine Concentration, and Hyperviscosity in a Patient With a Monoclonal IgM Paraprotein. Cureus 2023; 15:e41657. [PMID: 37565135 PMCID: PMC10411961 DOI: 10.7759/cureus.41657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 08/12/2023] Open
Abstract
A 76-year-old female followed closely for five years with IgM monoclonal gammopathy of uncertain significance developed anemia, worsened plasma creatinine concentration, and markedly elevated serum viscosity. This case illustrates the scope of pathology that can be caused by elevated blood viscosity. Our patient's anemia was a homeostatic response to normalize systemic vascular resistance and resulted from activation of the systemic vascular resistance response. The elevated plasma creatinine resulted from decreased renal perfusion because of elevated blood viscosity. Recent insights in hemorheology (the study of blood flow) are discussed, namely the recent identification of preferential blood flow patterns and erythrocyte autoregulation of deformability. These insights confirm that blood viscosity is part of the "milieu intérieur."
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Affiliation(s)
- Gregory D Sloop
- Pathology, Idaho College of Osteopathic Medicine, Meridian, USA
| | - Cheryl Moore
- Laboratory Services, Community Hospital of Monterey Peninsula, Monterey, USA
| | - Gheorghe Pop
- Cardiology, Radboud University Medical Center, Nijmegen, NLD
| | | | - John A St Cyr
- Cardiac/Thoracic/Vascular Surgery, Jacqmar Inc., Minneapolis, USA
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9
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Stoyanov A, Toong C, Kong Y, Chen R, Urriola N. Serum protein electrophoresis and rheumatoid factor analysis is an effective screening strategy for cryoglobulinaemia. Pathology 2023; 55:391-396. [PMID: 36494206 DOI: 10.1016/j.pathol.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/05/2022] [Accepted: 09/06/2022] [Indexed: 11/15/2022]
Abstract
Accurate serum cryoglobulin detection is important to allow prompt treatment but laboratory testing requires stringent pre-analytical conditions and has long turnaround times. Serum protein electrophoresis (EPG) for paraproteinaemia and rheumatoid factor (RF) analysis may offer an effective initial screening strategy for the presence of cryoglobulinaemia. We retrospectively assessed the sensitivity of ancillary EPG and RF testing for the presence of serum cryoglobulinaemia in 586 eligible cryoglobulin positive samples received at the Royal Prince Alfred and Liverpool Hospital immunopathology laboratories over an 11-year period. Ninety-one percent of all cryoglobulin positive samples had either a detectable paraprotein or RF activity, with greatest sensitivity for type I and type II cryoglobulins (97% and 98%, respectively). The sensitivity remained high irrespective of whether EPG and RF analysis was performed with the same, or different, pre-analytical collection conditions to the cryoglobulin collection (92% vs 90%, p=0.46). Only two patients with detected cryoglobulins and no associated paraprotein or RF activity had clinical features of cryoglobulinaemia and neither required treatment. This study demonstrates that serum EPG and RF analysis has high sensitivity for the detection of clinically relevant cryoglobulinaemia, even when not collected under ideal pre-analytical conditions, and potentially offers a prompt and effective screening strategy.
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Affiliation(s)
- Alex Stoyanov
- Central Sydney Immunopathology Laboratory, Pathology East, NSW Health Pathology, Sydney, NSW, Australia.
| | - Catherine Toong
- Department of Immunopathology, Liverpool Hospital, NSW Health Pathology, Sydney, NSW, Australia
| | - Yvonne Kong
- Department of Haematology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Renfen Chen
- Central Sydney Immunopathology Laboratory, Pathology East, NSW Health Pathology, Sydney, NSW, Australia
| | - Nicolás Urriola
- Department of Clinical Immunology, Royal Prince Alfred Hospital, Sydney, Australia
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10
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Lyubimova NV, Timofeev YS, Abaev VM, Votyakova OM, Osmanov EA, Kushlinskii NE. Biochemical profile of Bence-Jones type multiple myeloma. Klin Lab Diagn 2022; 67:570-574. [PMID: 36315171 DOI: 10.51620/0869-2084-2022-67-10-570-574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Multiple myeloma (MM) is a malignant tumor occurring from plasma cells that produce an abnormal monoclonal immunoglobulin - a paraprotein. A distinctive feature of Bence-Jones myeloma is the excretion of monoclonal free light chains of immunoglobulins with 24h urine, and the absence of monoclonal intact immunoglobulins secretion. Comprehensive analysis of biochemical parameters in blood serum and 24h urine in patients with Bence-Jones multiple myeloma using electrophoretic and immunoturbidimetric methods to assess their sensitivity as biomarkers. 50 patients with a morphologically confirmed diagnosis of MM of the Bence-Jones immunochemical type were examined. 28 people without oncological diseases were examinedas a control. Detection of monoclonal secretion in blood serum and daily urine was performed by immunofixation electrophoresis on the Hydrasys 2 electrophoretic system (Sebia). The determination of free light chains of immunoglobulins (FLC) was performed by the immunoturbidimetric method (Binding Site) on an Advia 1800 analyzer (Siemens). Analysis of IgG, IgA, IgM, β2-microglobulin and C-reactive protein was performed on Cobas 6000 analyzer (Roche). The median excretion of Bence-Jones protein in 24h urine of MM patients was 0.49 g/24h (0.06-2.45 g/24h). In the blood serum, in 86% of cases, the presence of paraproteinemia, represented by κ and λ type light chains of immunogloublins was detected. At the same time, the frequency of detection of monoclonal secretion in blood serum in Bence-Jones type λ myeloma was 95.7%, which was statistically significantly higher than the frequency of detection of monoclonal secretion of type κ - 77.8%. In patients with identified paraproteinemia, Bence-Jones protein excretion in daily urine (median 0.82 g/day) was statistically significantly higher than in patients without a monoclonal component detected in blood serum (median 0.04 g/24h). The levels of FLC in blood serum obtained by immunoturbidimetry in Bence-Jones myeloma of the corresponding type were higher than the reference levels in 100% of cases. The median level of κ-FLC reached 4358 mg/l, λ-FLC - 2225 mg/l, which was statistically significantly higher than the control levels. The median concentrations of IgG, IgA and IgM in patients with Bence-Jones myeloma were statistically significantly lower than in the control group, while the medians of β2-microglobulin and C-reactive protein were significantly higher than in the control. Our investigation showed high diagnostic efficiency of electrophoretic and immunoturbidimetric analysis of monoclonal secretion in patients with Bence-Jones MM, while FLC analysis demonstrated maximum sensitivity. Bence-Jones MM revealed biochemical signs of secondary immunodeficiency and general inflammatory syndrome.
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Affiliation(s)
- Nina Vasilyevna Lyubimova
- N.N. Blokhin National Medical Research Center of Oncology Ministry of Health of the Russian Federation
| | - Yu S Timofeev
- N.N. Blokhin National Medical Research Center of Oncology Ministry of Health of the Russian Federation
| | - V M Abaev
- N.N. Blokhin National Medical Research Center of Oncology Ministry of Health of the Russian Federation
| | - O M Votyakova
- N.N. Blokhin National Medical Research Center of Oncology Ministry of Health of the Russian Federation
| | - E A Osmanov
- N.N. Blokhin National Medical Research Center of Oncology Ministry of Health of the Russian Federation
| | - N E Kushlinskii
- N.N. Blokhin National Medical Research Center of Oncology Ministry of Health of the Russian Federation
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Loane SC, Castillo DA, Peschard ALDM, Hall HR, Kortum AJ. Spurious laboratory results associated with immunoglobulin M gammopathy in a dog with multiple myeloma. J Vet Intern Med 2022; 36:2181-2186. [PMID: 36125290 DOI: 10.1111/jvim.16540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 08/31/2022] [Indexed: 11/29/2022] Open
Abstract
An 11 year old female-neutered Labrador presented for facial swelling. Clinicopathological abnormalities included hyperglobulinemia, azotemia, hypercalcemia, nonregenerative anemia, thrombocytopenia, and spurious hypoglycemia. Normoglycemia was subsequently confirmed using a cage-side analyzer (AlphaTRAK, Zoetis, UK). Serum and urine protein electrophoresis documented monoclonal (immunoglobulin M) gammopathy with Bence-Jones proteinuria. Computed tomography imaging revealed a monostotic osteolytic bone-lesion, and bone marrow cytology and histopathology documented plasmacytosis with multiple myeloma oncogene 1 / interferon regulatory factor 4 positivity, consistent with multiple myeloma. Infectious disease testing initially indicated seropositivity for Leishmania, Borrelia, and Anaplasma spp.; however, Leishmania PCR (splenic and bone marrow aspirates), and paired serological titers for Borrelia and Anaplasma were negative. Consequently, initial serological results were considered to be false positive because of paraproteinemia-associated assay interference. Chemotherapy (prednisolone and melphalan combination therapy) was initiated, but the dog was euthanased 30 days later because of the development of pericardial effusion. This is a report of spurious serological (and other laboratory) results occurring secondary to monoclonal gammopathy in a dog.
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Affiliation(s)
- Samantha C Loane
- Department of Veterinary Medicine, University of Cambridge, Cambridge, Madingley Road, United Kingdom
| | - Daniel A Castillo
- Department of Veterinary Medicine, University of Cambridge, Cambridge, Madingley Road, United Kingdom
| | | | - Harriet R Hall
- Department of Veterinary Medicine, University of Cambridge, Cambridge, Madingley Road, United Kingdom
| | - Andre J Kortum
- Department of Veterinary Medicine, University of Cambridge, Cambridge, Madingley Road, United Kingdom
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Kim S, Bae W, Choi J, Lee TW, Song DH, Bae E, Jang HN, Chang SH, Park DJ. Acute kidney injury due to direct infiltration by lymphoplasmacytic lymphoma secreting IgG paraproteins: A case report. Medicine (Baltimore) 2022; 101:e29449. [PMID: 35713455 PMCID: PMC9276466 DOI: 10.1097/md.0000000000029449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/22/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Waldenström's macroglobulinemia is a lymphoplasmacytic lymphoma (LPL) associated with a monoclonal immunoglobulin M protein. Although acute kidney injury (AKI) due to immunoglobulin M paraprotein infiltration into the renal interstitium has been reported, there has been no report of AKI with invasion of the immunoglobulin G paraprotein into the renal interstitium in a patient with LPL. PATIENT CONCERNS A 65-year-old male was admitted to our hospital with fatigue and decreased renal function. He complained of a 3-kg weight loss in the last 3 months. DIAGNOSIS The initial blood urea nitrogen and serum creatinine levels were 55.9 and 1.83 mg/dL, respectively. Serum protein electrophoresis revealed a monoclonal component (3.5 g/dL) in the gamma region and immunofixation electrophoresis showed an immunoglobulin G kappa monoclonal protein. Renal pathology revealed that CD3-CD20+ CD138+ lymphoid cells had infiltrated the renal interstitium. A bone marrow biopsy was compatible with LPL. INTERVENTIONS Intravenous methylprednisolone (1 mg/kg) was administered after confirming the renal pathological findings. OUTCOMES Serum creatinine decreased to 0.8 mg/dL 14 days after treatment. CONCLUSIONS Physicians should recognize LPL secreting various immunoglobulins as a possible cause of AKI when renal failure of unknown etiology and serum immunoglobulin paraprotein is present. A kidney biopsy should be performed for definitive diagnosis and appropriate management.
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Affiliation(s)
- Seongmin Kim
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Wooram Bae
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Jungyoon Choi
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Tae Won Lee
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Dae Hyun Song
- Department of Pathology, Gyeongsang National University Changwon Hospital, Changwon, South Korea
- Department of Pathology, Gyeongsang National University College of Medicine
- Institute of Health Science, Gyeongsang National University, Jinju, South Korea
| | - Eunjin Bae
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea
- Department of Internal Medicine, Gyeongsang National University College of Medicine
- Institute of Health Science, Gyeongsang National University, Jinju, South Korea
| | - Ha Nee Jang
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, South Korea
| | - Se-Ho Chang
- Department of Internal Medicine, Gyeongsang National University College of Medicine
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, South Korea
- Institute of Health Science, Gyeongsang National University, Jinju, South Korea
| | - Dong Jun Park
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea
- Department of Internal Medicine, Gyeongsang National University College of Medicine
- Institute of Health Science, Gyeongsang National University, Jinju, South Korea
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13
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Flowers KC, Tuddenham E, Leiva A, Garrison L, Morris JE, Cromwell T, Boa FG. Negative interference from immunoglobulin M paraproteinaemia on the Roche enzymatic creatinine method. Ann Clin Biochem 2022; 59:205-210. [PMID: 35133213 DOI: 10.1177/00045632221074867] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although enzymatic creatinine methods are subject to fewer interferences than traditional Jaffe creatinine methods, every method in clinical chemistry has limitations. We report, for the first time in the literature, a case of an immunoglobulin M (IgM) paraproteinaemia causing an undetectably low creatinine result on the Roche enzymatic assay. This interference did not occur with other enzymatic creatinine methods produced by Abbott and Siemens or the Roche Jaffe, VITROS dry slide and liquid chromatography with tandem mass spectrometry (LC-MS/MS) creatinine methods. IgM interference was confirmed as patient serum precipitated with polyethylene glycol (PEG) and anti-IgM antiserum yielded detectable Roche enzymatic creatinine results comparable to unaffected methods. The patient's serum formed an obvious precipitate when mixed with reagent one of the Roche enzymatic creatinine method. This is in contrast to a report of positive interference from IgM paraproteinaemia in a different enzymatic creatinine method, which showed that a precipitate formed when mixing blood with reagent two. As each patient's paraprotein has a unique structure, it is possible that there are variations in the chemical characteristics of IgM paraproteins between patients. This, as well as IgM-class antibodies' tendency to form multimers and aggregates, can lead to unpredictable assay interferences and precipitation tendencies between different manufacturers of enzymatic creatinine reagents and their incubation steps. This case highlights the importance of continuing to question and investigates results that do not fit the clinical picture, especially as more laboratories switch from primarily using traditional Jaffe creatinine methods to enzymatic creatinine methods.
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Affiliation(s)
- Kade C Flowers
- Department of Clinical Blood Sciences, South West London Pathology, 4968St George's University Hospitals NHS Foundation Trust, London, UK
| | - Emma Tuddenham
- Department of Clinical Blood Sciences, South West London Pathology, 4968St George's University Hospitals NHS Foundation Trust, London, UK
| | - Anya Leiva
- 434486Parkshot Medical Practice, Richmond, UK
| | - Lisa Garrison
- Department of Clinical Blood Sciences, South West London Pathology, 4968St George's University Hospitals NHS Foundation Trust, London, UK
| | - Joanne E Morris
- Protein Reference Unit, South West London Pathology, 4968St George's Hospital, London, UK
| | - Tamsyn Cromwell
- Clinical Biochemistry and Immunology, Royal Sussex County Hospital, 8721University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Frances G Boa
- Department of Clinical Blood Sciences, South West London Pathology, 4968St George's University Hospitals NHS Foundation Trust, London, UK
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14
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Rekhtina IG, Mendeleeva LP, Soboleva NP, Dubina IA, Pervakova MI, Lapin SV. [Detection of paraprotein in plasma cell tumors]. TERAPEVT ARKH 2022; 94:135-144. [PMID: 36286929 DOI: 10.26442/00403660.2022.01.201326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/14/2022] [Indexed: 06/16/2023]
Abstract
Paraprotein is a laboratory biomarker of plasma cell tumors and other lymphoproliferative diseases. Its determination is necessary for diagnosing, monitoring and assessment of therapy effectiveness. The lecture presents the main methods of qualitative and quantative analysis of monoclonal proteins: gel electrophoresis, capillary electrophoresis, immunofixation and nephelometry features, possibilities and limitations are reviewed. The main sources of errors and artifacts during these studies are considered. Also the difficulties in the diagnosis and interpretation of the results of serum and urine tests are highlighted.
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Affiliation(s)
| | | | | | - I A Dubina
- Pavlov First Saint Petersburg State Medical University
| | - M I Pervakova
- Pavlov First Saint Petersburg State Medical University
| | - S V Lapin
- Pavlov First Saint Petersburg State Medical University
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15
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Nelson HA, Genzen JR, Delgado JC, Rudolf JW. An Interference in an Automated HCO3- Assay Leads to an Unexpected IgG Monoclonal Gammopathy Diagnosis. J Appl Lab Med 2021; 7:622-625. [PMID: 34849974 DOI: 10.1093/jalm/jfab126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/05/2021] [Indexed: 11/12/2022]
Affiliation(s)
- Heather A Nelson
- Department of Pathology, University of Utah, Salt Lake City, UT, USA.,ARUP Laboratories, Salt Lake City, UT, USA
| | - Jonathan R Genzen
- Department of Pathology, University of Utah, Salt Lake City, UT, USA.,ARUP Laboratories, Salt Lake City, UT, USA
| | - Julio C Delgado
- Department of Pathology, University of Utah, Salt Lake City, UT, USA.,ARUP Laboratories, Salt Lake City, UT, USA
| | - Joseph W Rudolf
- Department of Pathology, University of Utah, Salt Lake City, UT, USA.,ARUP Laboratories, Salt Lake City, UT, USA
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16
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Yilmaz NS, Sen B, Gulbahar O. Contribution of the laboratory to a diagnosis process by sequential reflective testing: Paraprotein interference on a direct bilirubin assay. Biochem Med (Zagreb) 2021; 31:020801. [PMID: 33927558 PMCID: PMC8047781 DOI: 10.11613/bm.2021.020801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/02/2021] [Indexed: 11/26/2022] Open
Abstract
Errors in laboratory medicine occur in the preanalytical, analytical, and postanalytical phases. The errors are mostly detected in the preanalytical period. However, analytical errors are still an important source of error, despite their frequency is reduced significantly in years thanks to developments in laboratories. In this case, an analytical error was noticed during the verification of a patient’s results. The direct bilirubin of a 66-year-old male patient admitted to the emergency department was higher than the total bilirubin. The patient’s symptoms were fatigue and dyspnoea. Albumin and haemoglobin (Hb) concentrations of the patient were significantly low. After considering the patient’s demographics and laboratory results, the laboratory specialist suspected a paraproteinemia interference. Total protein was performed as a reflective test. The albumin/globulin ratio was reversed. Thereafter, serum protein electrophoresis (SPEP) and immunofixation electrophoresis (IFE) were performed as another reflective tests, respectively. SPEP and IFE results were in favour of monoclonal gammopathy. The patient was directed to a haematologist, underwent a bone marrow biopsy, and the result was reported as Waldenstrom’s macroglobulinemia with plasma cell differentiation expressing IgM-Kappa. The patient went on a chemotherapy protocol, and his condition has been improved in subsequent months. Detection of analytical errors is of great importance, like in our case, and may be used as a tool to identify patients who have not yet been diagnosed. The laboratory specialist must dominate the entire process of each test in the laboratory, be aware of the limitations of tests, and turn these disadvantages into advantages when necessary.
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Affiliation(s)
- Niyazi Samet Yilmaz
- Department of Medical Biochemistry, Polatli Duatepe State Hospital, Ankara, Turkey
| | - Bayram Sen
- Department of Medical Biochemistry, Recep Tayyip Erdogan University Research and Training Hospital, Rize, Turkey
| | - Ozlem Gulbahar
- Department of Medical Biochemistry, Gazi University Faculty of Medicine, Ankara, Turkey
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17
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Whittle E, de Waal E, Huynh T, Treacy O, Morton A. Pre-analytical mysteries: A case of severe hypervitaminosis D and mild hypercalcaemia. Biochem Med (Zagreb) 2020; 31:011001. [PMID: 33380896 PMCID: PMC7745154 DOI: 10.11613/bm.2021.011001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/15/2020] [Indexed: 12/11/2022] Open
Abstract
We describe a case of severe hypervitaminosis D and mild hypercalcaemia in a 68-year-old woman who presented with fatigue and weight loss. Her 25-hydroxy vitamin D (25OHD) was > 400 nmol/L (50-150) and corrected serum calcium was 2.83 mmol/L (2.1-2.6). Her intact parathyroid hormone (PTH) was 4.9 pmol/L (2.0-9.5). Further investigation revealed an IgM kappa paraprotein, and a bone marrow aspirate confirmed a diagnosis of lymphoplasmacytic lymphoma/Waldenstrom’s macroglobulinemia (LPL/WM). As the vitamin D level was discordant with the patient’s other results and presentation, the presence of an assay interferent was suspected. A 1-in-2 dilution of the sample returned a 25OHD result of 84 nmol/L in keeping with the presence of an interferent. Testing for rheumatoid factor was negative. The sample was treated with an antibody blocking reagent (Scantibodies) and results were not consistent with heterophile antibody interference. The sample was then analysed using liquid chromatography tandem mass spectrometry (LC-MS/MS), which returned a 25OHD result of 82 nmol/L. Testing on an alternative immunoassay platform produced a 25OHD result of 75 nmol/L. Reapeted testing on the original platform following reduction of the monoclonal paraprotein with chemotherapy, returned a result of 64 nmol/L. The patient’s mild hypercalcaemia persisted following resolution of the monoclonal paraprotein, in keeping with a diagnosis of primary hyperparathyroidism. This case highlights the potential for paraproteins to cause assay interference, and the importance of considering interference when results are incongruous with the clinical presentation.
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Affiliation(s)
- Emma Whittle
- Department of Endocrinology and Diabetes, Mater Hospital, South Brisbane QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane QLD, Australia
| | - Elzahn de Waal
- Department of Chemical Pathology, Mater Pathology, South Brisbane QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane QLD, Australia
| | - Tony Huynh
- Department of Chemical Pathology, Mater Pathology, South Brisbane QLD, Australia.,Department of Endocrinology and Diabetes, Queensland Children's Hospital, South Brisbane QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane QLD, Australia
| | - Oliver Treacy
- Department of Chemical Pathology, Mater Pathology, South Brisbane QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane QLD, Australia
| | - Adam Morton
- Department of Endocrinology and Diabetes, Mater Hospital, South Brisbane QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane QLD, Australia
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18
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Pathak S, Rowczenio D, Lara-Reyna S, Kacar M, Owen R, Doody G, Krause K, Lachmann H, Doffinger R, Newton D, Savic S. Evidence of B Cell Clonality and Investigation Into Properties of the IgM in Patients With Schnitzler Syndrome. Front Immunol 2020; 11:569006. [PMID: 33424831 PMCID: PMC7793813 DOI: 10.3389/fimmu.2020.569006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 11/02/2020] [Indexed: 12/14/2022] Open
Abstract
The Schnitzler Syndrome (SchS) is an acquired, autoinflammatory condition successfully treated with IL-1 inhibition. The two main defining features of this late-onset condition are neutrophilic urticarial dermatoses (NUD) and the presence of an IgM monoclonal component. While the former aspect has been extensively studied in this disease setting, the enigmatic paraproteinaemia and its potential consequential effects within SchS, has not previously been thoroughly addressed. Previous studies analyzing clonal B cell repertoires have largely focused on autoimmune disorders such as Systemic Lupus Erythematous (SLE) and hematological malignancies such as Chronic Lymphocytic Leukaemia (CLL), where B-cell clonality is central to disease pathology. The present study uses next-generation sequencing to provide detailed insight into aspects of B cell VDJ recombination and properties of the resulting immunoglobulin chains. An overview of IgH regional dynamics in 10 SchS patients, with a particular focus on CDR3 sequences and VDJ gene usage is reported, highlighting the presence of specific B cell expansions. Protein microarray detected a substantial proportion of autoreactive IgM to nuclear target proteins, though a single universal target was not identified. Together, these genetic and functional findings impart new understanding into this rare disorder.
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Affiliation(s)
- Shelly Pathak
- National Institute for Health Research-Leeds Musculoskeletal Biomedical Research Centre and Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, United Kingdom
| | - Dorota Rowczenio
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Samuel Lara-Reyna
- National Institute for Health Research-Leeds Musculoskeletal Biomedical Research Centre and Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, United Kingdom
| | - Mark Kacar
- National Institute for Health Research-Leeds Musculoskeletal Biomedical Research Centre and Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, United Kingdom
| | - Roger Owen
- Department of Haematology, St James's University Hospital, Leeds, United Kingdom
| | - Gina Doody
- Division of Haematology and Immunology, Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom
| | - Karoline Krause
- Department of Dermatology and Allergy, Allergie-Centrum-Charité, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Helen Lachmann
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Rainer Doffinger
- Department of Clinical Biochemistry and Immunology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Darren Newton
- Division of Haematology and Immunology, Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom
| | - Sinisa Savic
- National Institute for Health Research-Leeds Musculoskeletal Biomedical Research Centre and Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, United Kingdom
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19
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Nair CK, Raghavan V, Bhattacharjee A, Kurup AR. Impact of early reduction in paraprotein on survival in transplant ineligible myeloma: Lesson from a tertiary cancer center in rural India. J Cancer Res Ther 2020; 16:88-93. [PMID: 32362614 DOI: 10.4103/jcrt.jcrt_459_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction The impact of rapid reduction in paraprotein levels, with induction chemotherapy in myeloma, on treatment outcomes is less clear. There are very few studies in transplant ineligible patients treated with novel agents, correlating an early reduction in paraprotein with survival duration. Methods In this retrospective analysis of newly diagnosed multiple myeloma, ineligible for stem cell transplant, paraprotein levels at baseline and 3 months were noted with percentage reduction. Survival analysis was performed with Kaplan-Meier curves and Cox proportional hazard model. Results Among a total of 121 patients, 42 (35%), 29 (24%), and 50 (41%) had paraprotein reduction of 100%, 90%-99%, and <90%, respectively from baseline levels at 3 months. Patients with complete disappearance of paraprotein (100% reduction) when compared against those with <100% reduction at 3 months had a trend toward higher overall survival (OS) (3-year OS of 81% vs. 69%, hazard ratio [HR] = 0.54, P = 0.182). However, the progression-free survival (PFS) was significantly higher when these two groups were compared (median PFS of 51 vs. 17 months, HR = 0.33, P ≤ 0.001). When patients with ≥90% reduction were compared with <90% reduction at 3 months, there was significant improvement in both OS and PFS (3-year OS of 80% vs. 48%, HR = 0.24, P = 0.001, median PFS of 38 vs. 14 months, HR = 0.13, P < 0.001). Conclusions Achieving a faster and deeper reduction in paraprotein as early as 3 months could lead to significant improvement in PFS.
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Affiliation(s)
- Chandran K Nair
- Department of Clinical Hematology and Medical Oncology, Malabar Cancer Centre, Kannur, Kerala, India
| | - Vineetha Raghavan
- Department of Clinical Hematology and Medical Oncology, Malabar Cancer Centre, Kannur, Kerala, India
| | - Atanu Bhattacharjee
- Division of Clinical Research and Biostatistics, Malabar Cancer Centre, Kannur, Kerala, India
| | - Anju R Kurup
- Department of Clinical Hematology and Medical Oncology, Malabar Cancer Centre, Kannur, Kerala, India
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20
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Strobel SL, Lunsford KL. Enhancing the Role of the Medical Technologist in Serum Protein Electrophoresis Interpretation: A Pattern Recognition Approach to Identifying Obvious and Potentially Significant Subtle Alterations. Ann Clin Lab Sci 2020; 50:670-673. [PMID: 33067214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Medical technologists who perform serum protein electrophoresis can provide valuable input and assistance in the interpretation of the electrophoretic pattern. Recognition of common alterations in conjunction with the utilization of standardized interpretation comments expedites the final interpretation performed by the clinical pathologist. Improved understanding of the clinical utility of the electrophoretic interpretation enhances the role and satisfaction of the medical technologists.
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Affiliation(s)
- Stephen L Strobel
- Department of Pathology, Bon Secours Mercy Health - St. Vincent Hospital, Toledo, OH, USA
| | - Kylie L Lunsford
- Department of Pathology, Bon Secours Mercy Health - St. Vincent Hospital, Toledo, OH, USA
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21
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Smirnov AV, Afanasyev BV, Poddubnaya IV, Dobronravov VA, Khrabrova MS, Zakharova EV, Nikitin EA, Lysenko Kozlovskaya LV, Bobkova IN, Rameev VV, Batyushin MM, Moiseev IS, Darskaya EI, Pirogova OV, Mendeleeva LP, Biryukova LS. [Monoclonal gammopathy of renal significance: consensus of hematologists and nephrologists of Russia on the establishment of nosology, diagnostic approach and rationale for clone specific treatment]. TERAPEVT ARKH 2020; 92:10-22. [PMID: 33346441 DOI: 10.26442/00403660.2020.07.000659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Indexed: 11/22/2022]
Abstract
Monoclonal gammopathy of renal significance (MGRS) is a new nosology in modern nephrology and oncohematology. MGRS is defined as kidney injury due to nephrotoxic monoclonal immunoglobulin produced by the B-cell line clone which does not reach the hematological criteria for specific treatment initiation. Monoclonal proteins pathological effects on kidney parenchyma result in irreversible decline of kidney function till the end stage renal disease that in line with the position of International Consensus of hematologists and nephrologists determinates critical necessity for clone specific treatment in patients with MGRS despite the absence of hematological indications for treatment initiation. Main challenge of MGRS in Russian Federation is an inaccessibility of an in-time diagnostic and appropriate treatment for the great majority of patients due to the following reasons: 1) limited knowledge about the MGRS among hematologists and nephrologists; 2) lack of necessary diagnostic resources in most health-care facilities; 3) lack of approved clinical recommendations and medical economic standards for treatment of this pathological entity. Consensus document comprises the opinion of experts leading nephrologists and hematologists of Russian Federation on the problem of MGRS including the incoherence in nosology classification, diagnostics approach and rationale for clone specific treatment. Consensus document is based on conclusions and agreements reached during the conference of leading nephrologists and hematologists of Russia which was held in the framework of symposia Plasma cell dyscrasias and lymphoproliferative diseases: modern approaches to therapy, 1516 of March 2019, Pavlov First Saint Petersburg State Medical University. The present Consensus is intended to define the principal practical steps to resolve the problem of MGRS in Russian Federation that are summarized as final clauses.
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Affiliation(s)
- A V Smirnov
- Pavlov First Saint Petersburg State Medical University
| | - B V Afanasyev
- Pavlov First Saint Petersburg State Medical University
| | - I V Poddubnaya
- Russian Medical Academy of Continuous Professional Education
| | | | - M S Khrabrova
- Pavlov First Saint Petersburg State Medical University
| | - E V Zakharova
- Russian Medical Academy of Continuous Professional Education.,Yevdokimov Moscow State University of Medicine and Dentistry.,Botkin City Clinical Hospital
| | - E A Nikitin
- Russian Medical Academy of Continuous Professional Education.,Botkin City Clinical Hospital
| | | | - I N Bobkova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - V V Rameev
- Sechenov First Moscow State Medical University (Sechenov University)
| | | | - I S Moiseev
- Pavlov First Saint Petersburg State Medical University
| | - E I Darskaya
- Pavlov First Saint Petersburg State Medical University
| | - O V Pirogova
- Pavlov First Saint Petersburg State Medical University
| | | | - L S Biryukova
- Russian Medical Academy of Continuous Professional Education.,National Research Center for Hematology
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22
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Smolej L. Incidence and prognostic significance of serum immunoglobulins and paraproteins in patients with chronic lymphocytic leukaemia: another valuable piece of the puzzle. Br J Haematol 2020; 190:815-816. [PMID: 32686123 DOI: 10.1111/bjh.16972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Lukáš Smolej
- 4th Department of Internal Medicine - Hematology, University Hospital and Faculty of Medicine, Hradec Králové, Czech Republic
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23
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Lomas OC, Mouhieddine TH, Tahri S, Ghobrial IM. Monoclonal Gammopathy of Undetermined Significance (MGUS)-Not So Asymptomatic after All. Cancers (Basel). 2020;12. [PMID: 32545521 PMCID: PMC7352603 DOI: 10.3390/cancers12061554] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/07/2020] [Accepted: 06/10/2020] [Indexed: 12/17/2022] Open
Abstract
Monoclonal Gammopathy of Undetermined Significance (MGUS) is considered to be a benign precursor condition that may progress to a lymphoproliferative disease or multiple myeloma. Most patients do not progress to an overt condition, but nevertheless, MGUS is associated with a shortened life expectancy and, in a minority of cases, a number of co-morbid conditions that include an increased fracture risk, renal impairment, peripheral neuropathy, secondary immunodeficiency, and cardiovascular disease. This review aims to consolidate current evidence for the significance of these co-morbidities before considering how best to approach these symptoms and signs, which are often encountered in primary care or within a number of specialties in secondary care.
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24
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Leitch S, Charlewood R. Paraprotein implicated in hardware failures in nucleic acid testing of blood donors. Vox Sang 2019; 115:140-147. [PMID: 31777099 DOI: 10.1111/vox.12870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Analyser blockage due to gel formation by paraproteins leading to invalid results is a rare problem in viral nucleic acid testing (NAT) at New Zealand Blood Service (NZBS) despite many blood samples tested without problems from individuals with known paraproteins. This study aimed to identify common factors in samples causing blockages. METHOD Retrospective data were gathered on blood samples known to have blocked analysers at NZBS testing sites. Patients with plasma cell dyscrasia undergoing haematopoietic stem cell (HSC) harvest formed the comparator arm. These patients were identified from registry data of individuals undergoing autologous stem cell transplantation at Auckland City Hospital between 2013 and 2017. RESULTS Four individuals were identified as having blocked analysers between 2010 and 2018. A total of 184 HSC transplant patients were identified, with contemporaneous paraprotein levels available for 177 (96%). Patients with intact immunoglobulin subtypes (134, 73%) were further analysed. Of these, 119 patients (65%) also had total protein and globulin levels available. Mean paraprotein (37.5 g/l), total protein (95.3 g/l), globulin levels (51.5 g/l) and proportion of lambda subtype (75%) were higher in the blocker group compared with non-blocking comparators (4.7 g/l, 66.8 g/l, 27.7 g/l, 36.6% respectively) (P = 0·03, 0·02, 0·007, 0·12). The highest paraprotein and total protein levels from the non-blocking cohort overlapped with the lowest of the blocker group. DISCUSSION High protein levels (paraprotein >20 g/l, total protein >75 g/l) and a trend towards lambda subtype were associated with NAT analyser blockage. The overlap with non-blocking donor samples suggests factors in addition to protein quantity that are also important.
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25
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Bora K, Chutia H. A peculiar reaction curve with dual spikes in absorbance during a total bilirubin assay in spite of accurate results induced by high M-protein concentration. Clin Chem Lab Med 2019; 57:e11-e14. [PMID: 29959885 DOI: 10.1515/cclm-2018-0369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/08/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Kaustubh Bora
- Haematology Group, ICMR - Regional Medical Research Centre, N.E. Region, Dibrugarh 786010, Assam, India.,Department of Biochemistry, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
| | - Happy Chutia
- Haematology Group, ICMR - Regional Medical Research Centre, N.E. Region, Dibrugarh 786010, Assam, India
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26
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Yavorkovsky LL, Jing W, Baker R. An upsurge of the serum free light chains as a possible missing link in tumour lysis syndrome in multiple myeloma. Br J Haematol 2019; 188:732-735. [PMID: 31573682 DOI: 10.1111/bjh.16231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 08/14/2019] [Indexed: 11/29/2022]
Abstract
Multiple myeloma (MM) is a slow-growing malignancy characterized by a low proliferation rate of plasma cells and a relatively rare incidence of tumour lysis syndrome (TLS). Three myeloma patients developed TLS following cytotoxic therapy (two after radiation treatment) that was associated with an abrupt increase of serum free light chains (FLC). All three patients demonstrated extramedullary plasmacytomas that exhibited aggressive features compared to the original myeloma. The findings suggested that an abrupt liberation (rather than slow secretion) of FLC from myeloma cells may trigger a fulminant cast nephropathy and present an unrecognized risk factor and potentially aggravating component of TLS.
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Affiliation(s)
| | - Wen Jing
- Pathology/Immunohistopathology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Robin Baker
- Pathology/Immunohistopathology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
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27
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Gendron N, Flament H, Litvinova E, Ortuno S, Ajzenberg N, Faille D. The (Fab)ulous Destiny of Idarucizumab: Highlighting Its Interference with Urine Protein Immunofixation. TH Open 2019; 3:e306-e308. [PMID: 31535075 PMCID: PMC6746617 DOI: 10.1055/s-0039-1697642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/05/2019] [Indexed: 10/27/2022] Open
Abstract
Idarucizumab is a humanized antigen binding fragment (Fab) of a recombinant anti-dabigatran monoclonal antibody (IgG1-kappa) that allows rapid and sustained reversal of dabigatran-induced anticoagulation in case of bleeding or urgent surgery. Herein, we report a very unusual case of dabigatran reversal by idarucizumab in a 79-year-old woman with acute kidney failure admitted to a hospital in a context of hemoptysis. Three repeated injections were necessary because of massive dabigatran overdose and high rebounds of dabigatran plasma concentration. Idarucizumab was found on urine immunofixation up to 6 days after the last injection where it reacted with anti-kappa light chain antibody, but not with anti-gamma heavy chain antibody. Physicians should be aware of the increased half-life of idarucizumab in this context of acute kidney impairment and of its interference with urine immunofixation because it could lead to false-positive results and misdiagnosis of a paraprotein.
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Affiliation(s)
- Nicolas Gendron
- Laboratoire d'Hématologie, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France.,Université de Paris, INSERM, U1148, Paris, France
| | - Héloïse Flament
- Laboratoire d'Immunologie-Hématologie, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France.,Université de Paris, INSERM, U1149, Paris, France
| | - Elena Litvinova
- Laboratoire d'Immunologie-Hématologie, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France.,Université de Paris, INSERM, U1149, Paris, France
| | - Sofia Ortuno
- Service de Néphrologie, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
| | - Nadine Ajzenberg
- Laboratoire d'Hématologie, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France.,Université de Paris, INSERM, U1148, Paris, France
| | - Dorothée Faille
- Laboratoire d'Hématologie, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France.,Université de Paris, INSERM, U1148, Paris, France
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Kritmetapak K, Dumrongsukit S, Jinchai J, Wongprommek P. Pseudohyperphosphatemia in a patient with relapsed multiple myeloma after bone marrow transplantation: A case report. Clin Case Rep 2019; 7:1426-1429. [PMID: 31360504 PMCID: PMC6637355 DOI: 10.1002/ccr3.2264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 05/10/2019] [Accepted: 05/28/2019] [Indexed: 11/11/2022] Open
Abstract
Pseudohyperphosphatemia is a laboratory artifact characterized by falsely elevated serum phosphate mostly due to paraprotein interference on the conventional automated analyzer. Clinician recognition of this phenomenon and pre-analytical preparation, including dilution or protein precipitation, can obviate unnecessary therapy and potentially unveil the diagnosis of paraproteinemia especially related to multiple myeloma.
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Affiliation(s)
| | - Sophon Dumrongsukit
- Department of Medicine, Faculty of MedicineKhon Kaen UniversityKhon KaenThailand
| | - Jittirat Jinchai
- Department of Medicine, Faculty of MedicineKhon Kaen UniversityKhon KaenThailand
| | - Panibud Wongprommek
- Division of Nephrology, Faculty of MedicineKhon Kaen UniversityKhon KaenThailand
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Briani C, Visentin A, Salvalaggio A, Cacciavillani M, Trentin L. Obinutuzumab, a new anti-CD20 antibody, and chlorambucil are active and effective in anti-myelin-associated glycoprotein antibody polyneuropathy. Eur J Neurol 2018; 26:371-375. [PMID: 30315672 DOI: 10.1111/ene.13838] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 10/08/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE Rituximab, a chimeric anti-CD20 monoclonal antibody, has been used in polyneuropathy associated with anti-myelin-associated glycoprotein (anti-MAG) antibody polyneuropathy with controversial results. Herein, two patients with anti-MAG antibody neuropathy and concurrent chronic lymphocytic leukemia (CLL) are reported, who dramatically responded to obinutuzumab, a novel glycoengineered humanized anti-CD20 monoclonal antibody. METHODS Patient 1 was an 82-year-old man with severe demyelinating sensory-motor neuropathy. He was wheelchair-bound, with loss of sensation up to the knees. He had a CLL, immunoglobulin M (IgM) lambda monoclonal gammopathy, with anti-MAG antibodies >70 000 Bühlmann titer units (BTU). Patient 2 was an 84-year-old woman with demyelinating neuropathy, paresthesias and gait instability. She had CLL and IgM kappa paraprotein with anti-MAG antibodies >70 000 BTU. Both patients were treated with obinutuzumab intravenously at 100 mg on day +1, 900 mg +2, then at 1000 mg on days 8 and 15 of cycle 1 and day 1 of cycles 2-6; chlorambucil was given orally at 0.5 mg/kg on days 1 and 15 of cycles 1-6. RESULTS Patient 1 at cycle 6 was able to stand, gait was possible with monolateral support, hypoesthesia and strength improved. M-protein and IgM level decreased. In patient 2, already after three cycles, the monoclonal component disappeared and there was dramatic improvement of symptoms and gait normalization. At the end of therapy anti-MAG antibody titer decreased to 5462 BTU. Neurophysiology also improved. CONCLUSIONS In our patients, obinutuzumab was effective as a first-line treatment of anti-MAG antibody polyneuropathy. CLL might have had a role in the response to therapy, but the associations might be considered in future trials.
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Affiliation(s)
- C Briani
- Neurology Unit, Department of Neuroscience, University of Padova, Padova, Italy
| | - A Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - A Salvalaggio
- Neurology Unit, Department of Neuroscience, University of Padova, Padova, Italy
| | | | - L Trentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, Padova, Italy
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30
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Preuss KD, Hollak CEM, Fadle N, van Oers M, Regitz E, Pfreundschuh M. Saposin C is a frequent target of paraproteins in Gaucher disease-associated MGUS/multiple myeloma. Br J Haematol 2018; 184:384-391. [PMID: 30450574 DOI: 10.1111/bjh.15659] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 09/15/2018] [Indexed: 01/21/2023]
Abstract
Patients with Gaucher disease (GD) have an increased risk of monoclonal gammopathies for which antigenic targets might play a role in their pathogenesis. Here we report the identification of saposin C (sapC) as high-titre (1:1 000 000) target structure of 7/16 GD-associated paraproteins. Anti-sapC immunoglobulin (Ig) showed identity with the paraprotein Ig type and subclass in each patient that showed anti-sapC immunoreactivity. Absorption and depletion studies completely removed the paraprotein from the sera of GD patients. No immunoreactivity against sapC was detected in healthy donors and in other plasma cell dyscrasias, demonstrating that anti-sapC reactivity is highly restricted to GD. Several uncharacterized forms of post-translational modified sapC were detected but their role in the pathogenesis is not clear. We confirm the frequent presence of low-titre (1:250) anti-lysolipid reactivities in the sera of GD patients but we could show that this immunoreactivity is not mediated by the paraprotein and is not restricted to GD patients.
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Affiliation(s)
- Klaus-Dieter Preuss
- Department of Internal Medicine I, José-Carreras-Centre, Saarland University Medical School, Homburg (Saar), Germany
| | - Carla E M Hollak
- Department of Endocrinology and Metabolism, Academic Medical Centre, Amsterdam, The Netherlands.,SPHINX, Amsterdam Lysosome Centre, Amsterdam, The Netherlands
| | - Natalie Fadle
- Department of Internal Medicine I, José-Carreras-Centre, Saarland University Medical School, Homburg (Saar), Germany
| | - Marinus van Oers
- Department of Haematology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Evi Regitz
- Department of Internal Medicine I, José-Carreras-Centre, Saarland University Medical School, Homburg (Saar), Germany
| | - Michael Pfreundschuh
- Department of Internal Medicine I, José-Carreras-Centre, Saarland University Medical School, Homburg (Saar), Germany
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31
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Hida T, Takahashi H, Takada K, Uhara H. Halo formations around senile hemangiomas in diffuse plane normolipemic xanthomatosis associated with monoclonal gammopathy. JAAD Case Rep 2018; 4:1034-1036. [PMID: 30456279 PMCID: PMC6232699 DOI: 10.1016/j.jdcr.2018.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Tokimasa Hida
- Department of Dermatology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hiroki Takahashi
- Department of Rheumatology and Clinical Immunology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Kohichi Takada
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hisashi Uhara
- Department of Dermatology, Sapporo Medical University School of Medicine, Sapporo, Japan
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Abstract
Monoclonal gammopathy of undetermined significance (MGUS) is characterised by the presence of a monoclonal paraprotein in the blood, without the characteristic end organ damage seen in multiple myeloma. MGUS is more common in older age groups and has a risk of progression to myeloma of 1% per year. Population screening is not currently recommended, but retrospective studies have suggested improvements in myeloma outcomes in those under MGUS follow-up; in addition, MGUS has associated complications, including fracture, osteoporosis, renal disease and infection, which can be treated. Given this increasing evidence of disease related directly to MGUS, strategies for early identification might be needed. In this review, we discuss the complications of MGUS and whether MGUS fulfils the criteria needed to implement a screening programme. We also highlight areas where more evidence is needed, including identification of a higher risk population to make screening more practical and economically viable.
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Affiliation(s)
- Catherine Atkin
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Alex Richter
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Elizabeth Sapey
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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Abstract
This case study presents a patient with multiple myeloma whose serum specimen exhibits 2 distinct bands in serum protein electrophoresis but only one band in immunofixation electrophoresis. This latter, single band corresponds to the M-spike. An investigation is presented to determine the identity of this disappearing or phantom band. Furthermore, this case is used as a teaching point to explain the criteria used for staging multiple myeloma, how a cell can become a myeloma propagating cell, methods that can be used to identify unexpected bands in serum protein electrophoresis, possible explanations for bands in the beta region, the usual treatment regimens in multiple myeloma and finally specimen collecting and handling procedures for serum protein electrophoresis.
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Affiliation(s)
- Linda Mamone
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA
| | - Jessica Jones
- Technical Services Unit, Helena Laboratories, Beaumont, TX
| | - Shiguang Liu
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA
| | - Yanhua Li
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA
| | - Barbara Goldsmith
- Division of Pathology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Adil I Khan
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA
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34
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Widmer CC, Balabanov S, Schanz U, Theocharides APA. Transient paraproteinemia after allogeneic hematopoietic stem cell transplantation is an underexplored phenomenon associated with graft versus host disease. Oncotarget 2017; 8:106333-41. [PMID: 29290952 DOI: 10.18632/oncotarget.22462] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Accepted: 10/27/2017] [Indexed: 01/12/2023] Open
Abstract
The clinical and biological relevance of a paraprotein that newly arises after allogeneic hematopoietic stem cell transplantation (allo-HSCT) in non-myeloma patients is unknown. In this study, the incidence, the course, and the clinical impact of paraproteins found after allo-HSCT were investigated in a cohort of 383 non-myeloma patients. Paraproteinemia after allo-HSCT was more frequent (52/383 patients, 14%) than the reported incidence of monoclonal gammopathy of unknown significance (MGUS) in age-matched healthy subjects and, in contrast to MGUS, did not correlate with age. In most patients (32/52, 62%), the paraprotein appeared transiently within the first year after allo-HSCT with a median duration of 6.0 months. Post-allo-HSCT paraproteinemia was significantly associated with graft versus host disease (GvHD) and correlated with a survival benefit within the first year, but not after five years following allo-HSCT. Importantly, patients with post-allo-HSCT paraproteinemia did not progress into a plasma cell myeloma as observed for MGUS inferring a distinct pathogenic mechanism. Skewing of lymphocyte subpopulations and alterations in cytokine levels in GvHD may explain the expansion of a specific plasma cell subset in non-myeloma patients undergoing allo-HSCT. Our data suggests that paraproteinemia after allo-HSCT is a reactive phenomenon rather than the consequence of clonal plasma cell transformation.
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35
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Alegría-Landa V, Cerroni L, Kutzner H, Requena L. Paraprotein deposits in the skin. J Am Acad Dermatol 2017; 77:1145-1158. [PMID: 28985955 DOI: 10.1016/j.jaad.2017.07.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 07/19/2017] [Accepted: 07/23/2017] [Indexed: 02/04/2023]
Abstract
Cutaneous manifestations secondary to paraprotein deposits in the skin include a group of different disorders that although rare, may be the first clinical manifestation of the underlying hematologic dyscrasia. In this article we review the clinical manifestations and histopathologic findings of the processes that result from specific deposition of the paraprotein in different structures of the skin. Paraneoplastic processes frequently associated with hematologic malignancies will not be covered in this review. Some of the disorders included here result from deposition of the intact paraprotein in the skin, whereas in other cases the lesions are due to deposition of modified paraproteins in the form of amyloid substance, cryoglobulins, or crystalglobulins. Cutaneous amyloidoma refers to nodular dermal deposits of amyloid derived from immunoglobulin light chains produced by local plasma cells in the absence of systemic amyloidosis. Dermatologists and dermatopathologists should be aware of the clinical and histopathologic features of these rare disorders because sometimes the cutaneous lesions are the first sign of an underlying silent hematologic malignancy with paraproteinemia.
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Affiliation(s)
| | - Lorenzo Cerroni
- Dermatopathology Research Unit, Medical University of Graz, Graz, Austria
| | - Heinz Kutzner
- Dermatopathologie Friedrichschafen, Friedrichschafen, Germany
| | - Luis Requena
- Department of Dermatology, Fundación Jiménez Diaz, Universidad Autónoma, Madrid, Spain.
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36
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Cox MC, Di Napoli A, Fabbri A, Cencini E, Ruco L. The significance of serum immunoglobulin paraprotein in diffuse large B-cell lymphoma. Br J Haematol 2017; 182:741-742. [PMID: 28832947 DOI: 10.1111/bjh.14873] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- M Christina Cox
- Haematology Unit, Azienda ospedaliera universitaria Sant'Andrea, Rome, Italy
| | - Arianna Di Napoli
- Department of Clinical and Molecular Medicine, Pathology Unit, La Sapienza University, Azienda ospedaliera universitaria Sant'Andrea, Rome, Italy
| | - Alberto Fabbri
- Unit of Haematology and Transplants, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Emanuele Cencini
- Unit of Haematology and Transplants, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Luigi Ruco
- Department of Clinical and Molecular Medicine, Pathology Unit, La Sapienza University, Azienda ospedaliera universitaria Sant'Andrea, Rome, Italy
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37
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García-González E, Aramendía M, González-Tarancón R, Romero-Sánchez N, Rello L. Detecting paraprotein interference on a direct bilirubin assay by reviewing the photometric reaction data. Clin Chem Lab Med 2017; 55:1178-1185. [PMID: 28076302 DOI: 10.1515/cclm-2016-0690] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 11/14/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND The direct bilirubin (D-Bil) assay on the AU Beckman Coulter instrumentation can be interfered by paraproteins, which may result in spurious D-Bil results. In a previous work, we took advantage of this fact to detect this interference, thus helping with the identification of patients with unsuspected monoclonal gammopathies. In this work, we investigate the possibility to detect interference based on the review of the photometric reactions, regardless of the D-Bil result. METHODS The D-Bil assay was carried out in a set of 2164 samples. It included a group of 164 samples with paraproteins (67 of which caused interference on the assay), as well as different groups of samples for which high absorbance background readings could also be expected (i.e. hemolyzed, lipemic, or icteric samples). Photometric reaction data were reviewed and receiver operating characteristics (ROC) curves were used to establish a cut-off for absorbance that best discriminates interference. RESULTS The best cut-off was 0.0100 for the absorbance at the first photometric point of the complementary wavelength in the blank cuvette. Once the optimal cut-off for probable interference was selected, all samples analyzed in our laboratory that provided absorbance values above this cut-off were further investigated to try to discover paraproteins. During a period of 6 months, we detected 44 samples containing paraproteins, five of which belonged to patients with non-diagnosed monoclonal gammopathies. CONCLUSIONS Review of the photometric reaction data permits the systematic detection of paraprotein interference on the D-Bil AU assay, even for samples for which reasonable results are obtained.
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Abstract
RATIONALE Crystalglobulinemia is a rare disease caused by monoclonal immunoglobulins, characterized by irreversible crystallization on refrigeration. It causes systemic symptoms including purpura, arthralgia, and vessel occlusive conditions to be exacerbated by exposure to cold. We report a patient with crystalglobulinemia associated with monoclonal gammopathy of undetermined significance (MGUS) manifesting as chronic arthralgia and recurrent acute arterial occlusion. PRESENTING CONCERNS A 61-year-old man, who had been diagnosed with MGUS and who had arthralgia of unknown origin, presented with recurrent acute limb ischemia after surgical thromboembolectomy. Refrigeration of his serum formed precipitates that looked like needle-shaped crystals. These crystals did not dissolve with warming, which is not a characteristic of cryoglobulins. Skin biopsy results showed crystal-liked eosinophilic bodies in small vessels and we diagnosed crystalglobulinemia. INTERVENTION AND OUTCOMES Although he underwent above-knee amputation, he was treated with a bortezomib and dexamethasone-based chemotherapeutic regimen, following lenalidomide maintenance therapy. Finally, he achieved complete remission and serum crystalglobulins diminished. LESSONS Monoclonal gammopathy, previously diagnosed as MGUS, can cause systemic symptoms and thrombotic conditions by producing pathologic immunoglobulins, such as crystalglobulins. In such situations, MGUS, even when it has not progressed to multiple myeloma, can be a target of aggressive chemotherapy. Crystalglobulinemia should be considered for patients with monoclonal gammopathy manifesting as systemic and thrombotic symptoms exacerbated by cooling.
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Batal I, Markowitz GS, Wong W, Avasare R, Mapara MY, Appel GB, D'Agati VD. Filgrastim-Induced Crescentic Transformation of Recurrent IgG2λ GN. J Am Soc Nephrol 2016; 27:1911-5. [PMID: 27147425 DOI: 10.1681/asn.2016010061] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Proliferative GN with monoclonal IgG deposits is an increasingly recognized form of GN, but its relation to hematologic malignancy remains poorly understood. Filgrastim, an analog for granulocyte colony-stimulating factor produced by recombinant DNA technology, is frequently used to stimulate bone marrow release of hematopoietic progenitor cells in preparation for stem cell transplant. We report an exceptional case of proliferative GN with monoclonal IgG2λ deposits in a young man whose disease progressed slowly to CKD, which was followed by a preemptive kidney transplant. The patient developed recurrent GN in the allograft and clinically detectable plasma cell neoplasm 9 years after the first renal manifestations. Contemporaneous with filgrastim administration for stem cell mobilization, the patient's slowly progressive GN underwent severe crescentic transformation, leading to rapidly progressive and irreversible allograft failure. This report explores the spectrum of GN with monoclonal IgG deposits and the pathophysiologic role of granulocyte colony-stimulating factor in exacerbation of preexisting GN.
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Affiliation(s)
- Ibrahim Batal
- Renal Pathology, Department of Pathology and Cell Biology,
| | | | | | | | - Markus Y Mapara
- Division of Hematology/Oncology and Columbia Center for Translational Immunology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
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40
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Dubina IA, Pervakova MY, Lapin SV, Emanuel VL, Totolian AA, Surkova EA, Gryazeva IV, Samoilovitch MP, Klimovitch VB. [The detection of level of free light chains of immunoglobulins using enzyme-linked immunosorbent assay techniques for diagnostic of monoclonal gammopathy.]. Klin Lab Diagn 2016; 61:781-786. [PMID: 31532951 DOI: 10.18821/0869-2084-2016-61-11-781-786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 05/15/2016] [Indexed: 11/17/2022]
Abstract
The content of free light chains of immunoglobulins kappa and lambda and also ratio of their concentrations in blood serum are important diagnostic and prognostic markers in case of monoclonal gammopathy. The technique FreelightTM based on nephelometric detection of free light chains using polyclonal antibodies is one of common modes of detection of free light chains. The actual study was carried out with purpose of validating of national test-system for detection of level of free light chains in blood serum using technique of enzyme-linked immunosorbent assay. The samples of blood serum were taken from 89 healthy donors and 165 patients with monoclonal gammopathy. To detect the level of free light chains enzyme-linked immunosorbent assay testsystem "Polygnost" was used based on application of monoclonal a ntibodies. The number of analytical characteristics of reagents set was determined including limit of detection and range of linearity. The limit of detection of free light chains using enzymelinked immunosorbent assay test-system was two times lower than claimed by manufacturer of nephelometric set "FreelightTM". Hence, analytical characteristics of enzyme-linked immunosorbent assay set make it possible to detect the level of free light chains within range of standard values. The reference limits were established concerning concentration of free light chains kappa (3.25-15.81 mkg/ml), free light chains lambda (3.23-28.05 mkg/ml) and their ratio (0.3-1.9) in blood serum that factually matched the recommended intervals for "FreelightTM" set. In patients with monoclonal gammopathy the level of free light chains was reliably higher (p<0.01) as compared with control group of healthy donors. In case of paraproteinemia reliable alteration (p<0.01) of ratio free light chains kappa/free light chains lambda was observed in comparison with control group. The results of actual study testify that national enzyme-linked immunosorbent assay set has good analytical and diagnostic characteristics and it can be used in laboratory practice.
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Affiliation(s)
- I A Dubina
- The I.P. Pavlov first St. Petersburg state medical university, 197022, St. Petersburg, Russia
| | - M Yu Pervakova
- The I.P. Pavlov first St. Petersburg state medical university, 197022, St. Petersburg, Russia
| | - S V Lapin
- The I.P. Pavlov first St. Petersburg state medical university, 197022, St. Petersburg, Russia
| | - V L Emanuel
- The I.P. Pavlov first St. Petersburg state medical university, 197022, St. Petersburg, Russia
| | - A A Totolian
- The Pasteur research institute of epidemiology and microbiology, 197101, St. Petersburg, Russia
| | - E A Surkova
- The I.P. Pavlov first St. Petersburg state medical university, 197022, St. Petersburg, Russia
| | - I V Gryazeva
- The Russian research center of radiology and surgical technologies, 197758, St. Petersburg, Russia
| | - M P Samoilovitch
- The Russian research center of radiology and surgical technologies, 197758, St. Petersburg, Russia
| | - V B Klimovitch
- The Russian research center of radiology and surgical technologies, 197758, St. Petersburg, Russia
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41
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Powell RJ, Leech SC, Till S, Huber PAJ, Nasser SM, Clark AT. BSACI guideline for the management of chronic urticaria and angioedema. Clin Exp Allergy 2015; 45:547-65. [PMID: 25711134 DOI: 10.1111/cea.12494] [Citation(s) in RCA: 136] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 12/11/2014] [Accepted: 01/09/2015] [Indexed: 12/11/2022]
Abstract
This guidance for the management of patients with chronic urticaria and angioedema has been prepared by the Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI). The guideline is based on evidence as well as on expert opinion and is aimed at both adult physicians and paediatricians practising in allergy. The recommendations are evidence graded. During the development of these guidelines, all BSACI members were included in the consultation process using a Web-based system. Their comments and suggestions were carefully considered by the Standards of Care Committee. Where evidence was lacking, a consensus was reached by the experts on the committee. Included in this management guideline are clinical classification, aetiology, diagnosis, investigations, treatment guidance with special sections on children with urticaria and the use of antihistamines in women who are pregnant or breastfeeding. Finally, we have made recommendations for potential areas of future research.
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Affiliation(s)
- R J Powell
- Department of Clinical Immunology and Allergy, Nottingham University, Nottingham, UK
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42
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Castillo B, Chang BN, Wahed A, Tholpady A. A Rare Case of Acquired Fanconi's Syndrome With Monoclonal Gammopathy in an Infant. J Clin Lab Anal 2015; 30:510-2. [PMID: 26511199 DOI: 10.1002/jcla.21888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 08/01/2015] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Monoclonal gammopathies associated with acquired Fanconi's syndrome (AFS) have been reported in the adult population. AFS is characterized by renal dysfunction resulting in proteinuria, aminoaciduria, hypophosphatemia, glucosuria, and hyperchloremic metabolic acidosis. In this case report, we document the clinical and laboratory findings of a preterm infant with features of both AFS and monoclonal gammopathy in the urine. METHODS Clinical suspicion of AFS prompted the following laboratory studies to be performed: urine protein electrophoresis (UPEP), urine immunofixation, and urine amino acid analysis with high performance liquid chromatography (HPLC). RESULTS Urine amino acid analysis revealed aminoaciduria. On UPEP, nonselective glomerular proteinuria was seen with a faint band in the gamma region. Urine immunofixation confirmed the presence of a monoclonal IgG lambda component with free monoclonal lambda light chains. CONCLUSION To the best of our knowledge, this is the first case of pediatric AFS reported with a monoclonal gammopathy and monoclonal free light chains.
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Affiliation(s)
- Brian Castillo
- Department of Pathology and Laboratory Medicine, University of Texas at Houston, Houston, Texas
| | - Brian N Chang
- Department of Pathology and Laboratory Medicine, University of Texas at Houston, Houston, Texas
| | - Amer Wahed
- Department of Pathology and Laboratory Medicine, University of Texas at Houston, Houston, Texas
| | - Ashok Tholpady
- Department of Pathology and Laboratory Medicine, University of Texas at Houston, Houston, Texas.
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Abstract
INTRODUCTION Gentamicin due to its low level of resistance and rapid bactericidal activity is commonly used to treat gram-negative bacteria. However, due to its toxic effects it needs to be monitored. To date, no interference has been reported with gentamicin assays. MATERIALS AND METHODS A patient with leg cellulitis and sepsis received a single dose of gentamicin and a sample was sent for gentamicin analysis. The sample showed high blank absorbance readings on Beckman DxC800 and DC800 analysers with various dilutions. A second sample was received and analysed on a Roche Cobas system to obtain a result. A third sample was received 107 hours later with the same results and this sample was then analysed neat and post ethanol precipitation on all the turbidimetric assays available on the DxC800 analyser. RESULTS The high blank absorbance was observed upon addition of the reactive reagents due to protein precipitation. Although not obvious from the patient protein results, it was shown the presence of high IgM paraprotein, 18.9 g/L (reference range 0.4-2.3 g/L) was the cause of precipitation, giving high blank readings. Of all the other turbidimetric assays, only vancomicin and valproate showed similar high blank absorbance readings. To be able to provide more rapid results it was shown ethanol could be used as a precipitant of proteins in both calibrators and patient samples with acceptable recovery. CONCLUSION IgM paraprotein was identified as the cause of interference with the gentamicin, vancomicin and valproate assays. Protein interference in these assays can be overcome by precipitation with ethanol.
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Affiliation(s)
- Goce Dimeski
- Department of Chemical Pathology, Pathology Queensland, Princess Alexandra Hospital, Brisbane, Australia
| | - Kendra Bassett
- Department of Chemical Pathology, Pathology Queensland, Princess Alexandra Hospital, Brisbane, Australia
| | - Nigel Brown
- Department of Chemical Pathology, Pathology Queensland, Princess Alexandra Hospital, Brisbane, Australia
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Li JJ, Henderson C. Cutaneous crystal storing histiocytosis: a report of two cases. J Cutan Pathol 2014; 42:136-43. [PMID: 25353627 DOI: 10.1111/cup.12413] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 09/07/2014] [Accepted: 10/07/2014] [Indexed: 11/29/2022]
Abstract
Crystal storing histiocytosis (CSH) is a rare condition where crystals accumulate in the cytoplasm of macrophages and is usually associated with a lymphoplasmacytic neoplasm producing a monoclonal immunoglobulin with kappa light chain. CSH with primary manifestation in the skin is extraordinarily rare and limited to four case reports in the literature. Here we present two cases of cutaneous CSH. One case is that of an 80 year old woman who presented with bilateral periorbital oedema with yellow discolouration. Skin biopsy showed dermal CSH in association with a neoplastic lymphoplasmacytoid infiltrate showing IgM kappa light chain restriction. Subsequent work up led to the discovery of Waldenstrom's macroglobulinemia. She had an indolent clinical course but died 6 years later from transformation into a diffuse large B cell lymphoma in the bone marrow. The other case is that of a 52 year old man who was recently diagnosed with multiple myeloma and developed a pruritic rash on his back during chemotherapy. Skin biopsy showed Grover disease (transient acantholytic dermatosis) and crystal storing macrophages in the superficial dermis. He died 4 years later after a protracted clinical course involving multiple cycles of chemotherapy and numerous complications. In both patients cutaneous CSH occurred early in the course of their lymphoplasmacytic malignancy and its development did not herald rapid clinical decline.
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Affiliation(s)
- Jing Jing Li
- Department of Anatomical Pathology, Liverpool Hospital, Liverpool, Australia
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Preuss KD, Fadle N, Regitz E, Held G, Pfreundschuh M. Inactivation of protein-phosphatase 2A causing hyperphosphorylation of autoantigenic paraprotein targets in MGUS/MM is due to an exchange of its regulatory subunits. Int J Cancer 2014; 135:2046-53. [PMID: 24676687 DOI: 10.1002/ijc.28864] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 03/13/2014] [Indexed: 01/20/2023]
Abstract
Hyperphosphorylated paratarg-7 (pP-7) carrier state is the strongest molecularly defined risk factor for monoclonal gammopathy of undetermined significance (MGUS), multiple myeloma (MM) and Waldenstrom's macroglobulinemia (WM). pP-7 is inherited as autosomal-dominant trait and depending on the ethnic background is found in over one-third of MGUS/MM patients. P-7, which is the antigenic paraprotein target in these patients, is hyperphosphorylated at serine17. P-7 hyperphosphorylation can be induced in wild-type P-7 (wtP-7) carriers by PKCζ and reverted by protein-phosphatase 2A (PP2A). Here we show that dephosphorylation of pP-7 is defective in pP-7 carriers due to inactivation of the PP2A by substitution of the regulatory B55δ subunit with B56γ3. In lymphoblastoid cell lines from pP-7 carriers, transfection of recombinant B55δ or treatment with ceramide led to a partial reconstitution of PP2A activity and dephosphorylation of pP-7 to wtP7. Similar results were observed with other previously reported autoantigenic paraproteins targets. In conclusion, the mechanisms responsible for the defective dephosphorylation and maintaining the hyperphosphorylated state of P-7 and other autoantigenic paraprotein targets have been elucidated, facilitating the identification of the genetic basis underlying this phenomenon which is obviously common in the pathogenesis of MGUS/MM/WM and not restricted to pP-7 cases.
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Affiliation(s)
- Klaus-Dieter Preuss
- José-Carreras-Center for Immuno- and Gene Therapy, Internal Medicine I, Saarland University Medical School, Homburg (Saar), Germany
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Cho SY, Jeon YL, You E, Lee HJ, Park TS. Interpretation and clinical significance of small monoclonal peaks in capillary electrophoresis. Ann Clin Lab Sci 2013; 43:285-288. [PMID: 23884223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Although the testing mechanism and interpretation criteria for capillary electrophoresis differ from those for gel-based electrophoresis, there are not that many reports on the efficacy of capillary electrophoresis. MATERIALS AND METHODS We performed a retrospective analysis, using the Laboratory Information System (LIS) to review a total of 163 capillary electrophoresis results from 117 different patients treated in our hospital between March and August 2012. Capillary electrophoresis was performed on capillary2 (Sebia, Lysse, France). RESULTS Among the patients' group, 4 patients presented very small M-peaks in capillary electrophoresis. By using the zoom function in capillary electrophoresis, two of them were confirmed to have monoclonality, but the remaining two required reconfirmation in gel electrophoresis, leading to confirmation of a discrete monoclonal band. CONCLUSION In this study, we found that small peaks in capillary electrophoresis accompanying a skewed K/L ratio deserve particular attention as they can grow into larger peaks within a few months. We suggest that any trivial M-peak in capillary electrophoresis should not be overlooked and that a combination of platform tests such as gel electrophoresis or FLC assay be implemented in order to confirm monoclonality.
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Affiliation(s)
- Sun Young Cho
- Department of Laboratory Medicine, Kyung Hee University School of Medicine, 1 Hoegi-dong, Dongdaemoon-gu, Seoul 130-702, Korea
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Thakkinstian A, Tran H, Reeves G, Murch S, Attia J. A clinical decision rule to aid ordering of serum and urine protein electrophoresis for case-finding of paraproteins in hospitalized inpatients. J Gen Intern Med 2008; 23:1688-92. [PMID: 18665429 DOI: 10.1007/s11606-008-0712-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2007] [Revised: 02/08/2008] [Accepted: 06/16/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To develop a simple clinical decision rule that could increase the yield of serum and urine protein electrophoresis (SPE/UPE) without loss of sensitivity. DESIGN A cross-sectional study of inpatients with a SPE/UPE performed over a 5-year period (2001-2006) with complete data on electrolytes, globulins, full blood count, creatinine, age, and gender. SETTING A tertiary-care general teaching hospital serving the Hunter Valley in New South Wales, with a referral population of over 1 million. PARTICIPANTS A total of 14,374 adult patients admitted between January 2001-November 2006. MAIN OUTCOME MEASURES Paraprotein on serum and/or urine protein electrophoresis (SPE/UPE). RESULTS Five points were assigned for globulin > 41 g/l, 3 points for age > or = 60, 2 points for each of hemoglobin < 121 and male gender, and 1 point for estimated glomerular filtration rate (eGFR) < 60. Total scores of 0-5, 6-10, and > or = 11 corresponded to positive likelihood ratios of an abnormal SPE/UPE of 1, 2.5, and 6.6, respectively. The predictive ability of this model was strong, with an area under the curve of approximately 0.8. Results in the validation set were almost identical. CONCLUSION A clinical decision rule using simple clinical variables has the potential to improve the yield of SPE/UPE. This rule however needs to be verified prospectively.
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Jeziorska M, Hassan A, Mackness MI, Woolley DE, Tullo AB, Lucas GS, Durrington PN. Clinical, biochemical, and immunohistochemical features of necrobiotic xanthogranulomatosis. J Clin Pathol 2003; 56:64-8. [PMID: 12499438 PMCID: PMC1769859 DOI: 10.1136/jcp.56.1.64] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2002] [Indexed: 11/04/2022]
Abstract
AIMS To describe the clinical features of two patients with paraproteinaemia and necrobiotic xanthogranulomatosis together with detailed immunohistochemistry of the lesions in one. METHODS The clinical history and results of biochemical investigations of the patients were retrieved from the files. Immunohistochemistry was used to investigate the expression of macrophage and mast cell markers, amyloid A and P, S-100 protein, and apolipoprotein AI and B in xanthogranulomatous skin lesions from patient 2. In addition, protein A-sepharose chromatography was used to separate serum from patient 2 and apolipoprotein B and the IgG paraprotein were measured in the fractions eluted. RESULTS Monocytes/macrophages comprised the major cellular component of the lesion, and unusually for xanthomata, areas of collagen necrosis were also seen. Activated mast cells were present at the margins of macrophage clusters and adjacent to areas of collagen necrosis. Serum paraprotein was bound to low density lipoproteins as judged by protein A-sepharose chromatography, and was also located within macrophagic foam cells of the lesion on immunohistochemistry. CONCLUSIONS These observations demonstrate many features similar to atherosclerosis including collagen necrosis and mast cell activation.
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Affiliation(s)
- M Jeziorska
- Department of Medicine, University of Manchester, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
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Abstract
This review describes the progress made in preparing Cochrane systematic reviews of randomized controlled trials for Guillain-Barré syndrome (GBS), chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), multifocal motor neuropathy (MMN) and the demyelinating neuropathies associated with paraproteins. The discovery of antibodies against myelin and axolemmal glycolipids and proteins has not yet replaced the clinicopathological classification on which treatment trials have been based. Systematic reviews have endorsed the equivalence of plasma exchange (PE) and intravenous immunoglobulin (IVIg) and the lack of efficacy of steroids in GBS. Systematic reviews have also endorsed the value of steroids, PE and IVIg in CIDP but randomized controlled trials have only shown benefit from IVIg in MMN. There is a paucity of evidence concerning the efficacy of treatments in paraproteinaemic demyelinating neuropathy apartment from small trials showing short-term benefit from PE or IVIg. There is a lack of good quality controlled trials of immunosuppressive agents in any of these conditions. As the number of treatment trials increases, Cochrane systematic reviews will be an increasingly valuable resource for summarizing the evidence from randomised controlled trials on which to base clinical practice. They already demonstrate major deficiencies in the existing evidence base.
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Affiliation(s)
- R A C Hughes
- Cochrane Neuromuscular Disease Review Group, Guy's, King's and St Thomas' School of Medicine, Guy's Hospital, London, UK
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