Clinical Chemistry 60:7 1019–1029 (2014)
What Is Your Guess?
The Missing Band Dina N. Greene*
Fig. 1. Serum immunofixation electrophoresis. Arrow denotes application point. Lanes labeled according to the antiserum applied (G, anti-IgG; D, anti-IgD; E, anti-IgE; K, total kappa; FKS, free kappa using antisera manufactured by Sebia; FKH, free kappa using antisera manufactured by Helena; L, total lambda; FLS, free lambda using antisera manufactured by Sebia; FLH, free lambda using antisera manufactured by Helena); ⫻2 denotes that the sample was run using 50 L of the sample diluted in 50 L of water.
CASE DESCRIPTION A 68-year-old woman with a bone marrow biopsy positive for kappa monotypic plasma cells (approximately 90% total) and flow cytometric analysis showing kappa-restricted plasma cells (approximately 17% of total) had unremarkable serum and urine immunofixation electrophoresis (Fig. 1). Her serum protein electrophoresis was remarkable for hypogammaglobulinemia [IgG 563 mg/dL (reference interval 600–1600 mg/dL), IgA 73 mg/dL (40–375 mg/dL), IgM 17 mg/dL (30–190 mg/dL)]. Serum free light chain (sFLC) results were consistent with the bone marrow biopsy: kappa-sFLC 668 mg/L (3.3–19.4 mg/dL); lambda-sFLC 6.0 mg/dL (5.7–23.3 mg/dL). All serum results were repeated with a second sample. QUESTIONS 1. What type of plasma cell dyscrasia is associated with these results? 2. How should this patient be monitored? The answers are below. ANSWERS Nonsecretory myelomas are defined by a clinical and anatomical diagnosis of plasma cell dyscrasia with un-
Kaiser Permanente, TPMG Northern California Regional Laboratory, Berkeley, CA. * Address correspondence to this author at: 1725 Eastshore Hwy., Berkeley, CA 94709. Fax 510-559-5306; e-mail [email protected]. Received November 15, 2013; accepted December 11, 2013.
detectable monoclonal protein in the serum (1 ). Studies have shown that many of these patients will have detectable FLC in their serum using nephelometry
DOI: 10.1373/clinchem.2013.219121 © 2013 American Association for Clinical Chemistry
1019
What Is Your Guess? techniques, and these assays can therefore be used to aid in diagnosis and monitoring (2 ).
Authors’ Disclosures or Potential Conflicts of Interest: No authors declared any potential conflicts of interest.
References Author Contributions: All authors confirmed they have contributed to the intellectual content of this paper and have met the following 3 requirements: (a) significant contributions to the conception and design, acquisition of data,oranalysisandinterpretationofdata;(b)draftingorrevisingthearticlefor intellectual content; and (c) final approval of the published article.
1. Lonial S, Kaufman JL. Non-secretory myeloma: a clinician’s guide. Oncology (Williston Park) 2013;27:924 – 8, 930. 2. Drayson M, Tang LX, Drew R, Mead GP, Carr-Smith H, Bradwell AR. Serum free light-chain measurements for identifying and monitoring patients with nonsecretory multiple myeloma. Blood 2001;97:2900 –2.
Plasma Abnormalities Following Overdose Daniel D. Rhoads,1 Richard A. Sivak,1 and Octavia M. Peck Palmer1,2*
CASE DESCRIPTION A 62-year-old female with a history of schizophrenia was found unresponsive after ingesting supratherapeutic amounts of diltiazem and valsartan. At presentation to the emergency department, she was hypotensive and bradycardic. Eight hours later, a blood sample (Fig. 1A) was drawn for chemistry analysis and ultracentrifuged to clarify the turbidity (Fig. 1B). However, the lab was unable to assay the plasma sample. Multiple samples yielded similar findings. Plasma samples obtained the following day were appropriate for analysis.
QUESTIONS 1. What interfering substances are causing the plasma’s strawberry milk appearance? 2. What off-label medication was administered to this patient? 3. What drug(s) may be responsible for causing the abnormal appearance of her plasma? The answers are below. ANSWERS The combination of lipemia and hemolysis caused the plasma’s strawberry milk appearance. Lipid emulsion is designed to be infused slowly as part of a total paren-
1
University of Pittsburgh Medical Center, Pittsburgh, PA; 2 Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA. * Address correspondence to this author at: University of Pittsburgh School of Medicine, 3477 Euler Way, Room 3014, Pittsburgh, PA 15213. Fax 412-6478567; e-mail [email protected]. Received November 20, 2013; accepted December 11, 2013. DOI: 10.1373/clinchem.2013.219212 © 2013 American Association for Clinical Chemistry
1020 Clinical Chemistry 60:7 (2014)
teral nutrition regimen. However, this patient received a 120-mL IV bolus of lipid emulsion off-label for its “lipid sink” action against supratherapeutic levels of lipid soluble drugs, such as diltiazem (1 ). Both lipid emulsion and diltiazem can cause erythrocyte fragility, which may account for the in vivo hemolysis (2–5 ).
Author Contributions: All authors confirmed they have contributed to the intellectual content of this paper and have met the following 3 requirements: (a) significant contributions to the conception and design, acquisition of data, or analysis and interpretation of data; (b) drafting
What Is Your Guess?
The Missing Band Dina N. Greene*
Fig. 1. Serum immunofixation electrophoresis. Arrow denotes application point. Lanes labeled according to the antiserum applied (G, anti-IgG; D, anti-IgD; E, anti-IgE; K, total kappa; FKS, free kappa using antisera manufactured by Sebia; FKH, free kappa using antisera manufactured by Helena; L, total lambda; FLS, free lambda using antisera manufactured by Sebia; FLH, free lambda using antisera manufactured by Helena); ⫻2 denotes that the sample was run using 50 L of the sample diluted in 50 L of water.
CASE DESCRIPTION A 68-year-old woman with a bone marrow biopsy positive for kappa monotypic plasma cells (approximately 90% total) and flow cytometric analysis showing kappa-restricted plasma cells (approximately 17% of total) had unremarkable serum and urine immunofixation electrophoresis (Fig. 1). Her serum protein electrophoresis was remarkable for hypogammaglobulinemia [IgG 563 mg/dL (reference interval 600–1600 mg/dL), IgA 73 mg/dL (40–375 mg/dL), IgM 17 mg/dL (30–190 mg/dL)]. Serum free light chain (sFLC) results were consistent with the bone marrow biopsy: kappa-sFLC 668 mg/L (3.3–19.4 mg/dL); lambda-sFLC 6.0 mg/dL (5.7–23.3 mg/dL). All serum results were repeated with a second sample. QUESTIONS 1. What type of plasma cell dyscrasia is associated with these results? 2. How should this patient be monitored? The answers are below. ANSWERS Nonsecretory myelomas are defined by a clinical and anatomical diagnosis of plasma cell dyscrasia with un-
Kaiser Permanente, TPMG Northern California Regional Laboratory, Berkeley, CA. * Address correspondence to this author at: 1725 Eastshore Hwy., Berkeley, CA 94709. Fax 510-559-5306; e-mail [email protected]. Received November 15, 2013; accepted December 11, 2013.
detectable monoclonal protein in the serum (1 ). Studies have shown that many of these patients will have detectable FLC in their serum using nephelometry
DOI: 10.1373/clinchem.2013.219121 © 2013 American Association for Clinical Chemistry
1019
What Is Your Guess? techniques, and these assays can therefore be used to aid in diagnosis and monitoring (2 ).
Authors’ Disclosures or Potential Conflicts of Interest: No authors declared any potential conflicts of interest.
References Author Contributions: All authors confirmed they have contributed to the intellectual content of this paper and have met the following 3 requirements: (a) significant contributions to the conception and design, acquisition of data,oranalysisandinterpretationofdata;(b)draftingorrevisingthearticlefor intellectual content; and (c) final approval of the published article.
1. Lonial S, Kaufman JL. Non-secretory myeloma: a clinician’s guide. Oncology (Williston Park) 2013;27:924 – 8, 930. 2. Drayson M, Tang LX, Drew R, Mead GP, Carr-Smith H, Bradwell AR. Serum free light-chain measurements for identifying and monitoring patients with nonsecretory multiple myeloma. Blood 2001;97:2900 –2.
Plasma Abnormalities Following Overdose Daniel D. Rhoads,1 Richard A. Sivak,1 and Octavia M. Peck Palmer1,2*
CASE DESCRIPTION A 62-year-old female with a history of schizophrenia was found unresponsive after ingesting supratherapeutic amounts of diltiazem and valsartan. At presentation to the emergency department, she was hypotensive and bradycardic. Eight hours later, a blood sample (Fig. 1A) was drawn for chemistry analysis and ultracentrifuged to clarify the turbidity (Fig. 1B). However, the lab was unable to assay the plasma sample. Multiple samples yielded similar findings. Plasma samples obtained the following day were appropriate for analysis.
QUESTIONS 1. What interfering substances are causing the plasma’s strawberry milk appearance? 2. What off-label medication was administered to this patient? 3. What drug(s) may be responsible for causing the abnormal appearance of her plasma? The answers are below. ANSWERS The combination of lipemia and hemolysis caused the plasma’s strawberry milk appearance. Lipid emulsion is designed to be infused slowly as part of a total paren-
1
University of Pittsburgh Medical Center, Pittsburgh, PA; 2 Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA. * Address correspondence to this author at: University of Pittsburgh School of Medicine, 3477 Euler Way, Room 3014, Pittsburgh, PA 15213. Fax 412-6478567; e-mail [email protected]. Received November 20, 2013; accepted December 11, 2013. DOI: 10.1373/clinchem.2013.219212 © 2013 American Association for Clinical Chemistry
1020 Clinical Chemistry 60:7 (2014)
teral nutrition regimen. However, this patient received a 120-mL IV bolus of lipid emulsion off-label for its “lipid sink” action against supratherapeutic levels of lipid soluble drugs, such as diltiazem (1 ). Both lipid emulsion and diltiazem can cause erythrocyte fragility, which may account for the in vivo hemolysis (2–5 ).
Author Contributions: All authors confirmed they have contributed to the intellectual content of this paper and have met the following 3 requirements: (a) significant contributions to the conception and design, acquisition of data, or analysis and interpretation of data; (b) drafting
