CASES sTUDY #2 lupus A 24-year-old woman had been complaining of multiple joint and muscular pains and stiffness in the morning. She also noted some hair loss and increased skin sensitivity to light. Her physical examination showed slight erythema around the cheek bones and some swelling in the joints of her hands. Studies Results Routine laboratory work Within normal limits (WNL), except for mild anemia Urinalysis, p. 956 Profuse proteinuria and cellular casts Antinuclear antibody (ANA), p. 88 1:256 (normal: <1:20) Anti-DNA 398 units (normal: <70 units) Anti-ENA Positive (normal: negative) Anticardiolipin antibody (ACA), p. 68 Immunoglobulin (Ig) G 96 g/L (normal: <23 g/L) IgM 78 mg/L (normal: <11 mg/L) Erythrocyte sedimentation rate (ESR), p. 221 75 mm/hour (normal: ≤20 mm/hour) Immunoglobulin electrophoresis, p. 312 IgG 1910 mg/dL (normal: 565-1765 mg/dL) IgA 450 mg/dL (normal: 85-385 mg/dL) IgM 475 mg/dL (normal: 55-375 mg/dL) Total complement assay, p. 172 22 hemolytic units/mL (normal: 41-90 hemolytic units/mL) Diagnostic Analysis The positive ANA and ACA tests strongly supported the diagnosis of systemic lupus erythematosus (SLE). The patient also had a facial rash suggestive of SLE. The elevated ESR indicated a systemic inflammatory process. The immunoelectrophoresis results were compatible with either RA or SLE; however, a decreased complement assay is commonly associated with SLE. The abnormal urinalysis indicated that the kidneys also were involved with the disease process. The patient was treated with steroids and did well for 7 years. Unfortunately, her renal function deteriorated, and she required chronic renal dialysis. Critical Thinking Questions 1. Explain the significance of the urinalysis results as they relate to renal involvement with SLE. 2. Why is the ESR increased in inflammatory conditions? CASE STUDY # 3 MULTIPLE MYELOMA Multiple Myeloma Case Studies A 64-year-old physician recently noted excessive tiredness throughout the day. He also complained of right hip/buttock pain. This prompted laboratory testing. On physical examination he was found to have an elevated heart rate (100 per minute) and appeared pale. Studies Results Routine laboratory data Normal except as indicated below CBC, p. 174 WBCs = 24,000 (normal: 5000-10,000) Hgb = 8.2 (normal: 14-18 g/dL) Hct = 25 (normal: 42%-52%) Differential indicates increase in mononuclear cells Albumin, p. 424 2.8 g/dL (normal: 3.5 to 5) Protein electrophoresis, p. 424 Immunoglobulin spike Immunofixation Spike in beta 2 microglobulin Beta-2 microglobulin, serum, p. 362 4.2 g/mL (normal: 0.70-1.80 mcg/mL) Multiple myeloma, urine, p. 911 4000 mcg/L (normal: less than 300 mcg per mL) Laboratory cytogenetics, p. 161 Deletion noted in chromosome 13 Multiple genetic translocations noted X-ray, right hip, p. 1006 Multiple radiolucent spots in the right ileum and femur Diagnostic Analysis This patient has marked anemia associated with elevated mononuclear (plasma) cell count. The RBCs are reduced because of the tumor burden affecting the marrow’s ability to make RBCs. Elevated levels of beta-2 microglobulin are noted, compatible with multiple myeloma. Laboratory cytogenetics supports the finding. The radiolucent changes noted in the right hip are the cause of his pain. The physician received aggressive chemotherapy that was successful in reducing his protein markers for 2 years. Unfortunately, he relapsed. He required further chemotherapy and bone marrow transplantation. He is now doing well and is quite active. Critical Thinking Questions 1. What other diseases are associated with an elevated white blood cell count? 2. What are the risks of the disease affecting the patient’s bones? 3. What is the name of proteins commonly in the urine of patients with multiple myeloma? 4. Why was the albumin abnormally low? 5. What tests will be used to monitor this man’s disease? |
A 24-year-old woman had been complaining of multiple joint and muscular pains and stiffness in the morning.

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