A 24-year-old woman had been complaining of multiple joint and muscular pains and stiffness in the morning.

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
Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 5th Edition

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?