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  #1  
Old 09-29-2011
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Question Case with osteolytic bone lesions!

A 43-year-old woman was admitted to the hospital with a 2-week history of nausea and vomiting. Five months earlier, she had gone to her primary care physician because of back pain and was found to have multiple thoracic and lumbar vertebral fractures that were thought to be due to osteoporosis. A DEXA scan had revealed osteopenia, more than 1.5 standard deviations below the mean, and the patient was treated with alendronate, vitamin D, calcium supplements, and ibuprofen prn. When the nausea and vomiting began 2 weeks before admission, alendronate and ibuprofen were discontinued, and she was given cimetidine, without improvement. Her medical history included iron deficiency anemia, for which she was taking iron supplementation. She had no history of alcohol, tobacco, or drug use. Examination of the head, neck, breasts, heart, lungs, abdomen, and extremities was unremarkable. Laboratory values were blood urea nitrogen (BUN) 35 mg/dL, creatinine 4.8 mg/dL, hematocrit 29.6%, mean corpuscular volume 84 µm3, calcium 13.1 mg/dL, total protein 6.6 g/dL, albumin 3.7 g/dL, and phosphate 1.8 mg/dL. Levels of ALT, AST and alkaline phosphatase were normal. Skeletal survey showed diffuse osteolytic lesions and several spinal compression fractures. Quantitative immunoglobulin studies revealed hypogammaglobulinemia with a serum IgG value of 456 mg/dL (normal, 700 to 1,700 mg/dL), IgA of 15 mg/dL (normal, 70 to 350 mg/dL), and IgM of 19 mg/dL (normal, 50 to 300 mg/dL).

Which of the following statements regarding the patient's disease is not correct ?

A) The lytic lesions in bone scan could be due to increased levels of osteoclast-activating factor.
B) The ESR may be increased in this patient.
C) The tumor cells produce massive quantities of different and multiple immunoglobulin molecules that are demonstrable as several narrow serum bands in electrophoresis
D) Densitometry could show a sharp spike referred to an M protein.
E) The patient has a malignant plasma cell tumor with possible renal involvement
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  #2  
Old 09-30-2011
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i think the answer is [D]
??
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  #3  
Old 09-30-2011
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A) The lytic lesions in bone scan could be due to increased levels of osteoclast-activating factor ???
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  #4  
Old 09-30-2011
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C) The tumor cells produce massive quantities of different and multiple immunoglobulin molecules that are demonstrable as several narrow serum bands in electrophoresis
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  #5  
Old 09-30-2011
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Colleagues!!!
Let's first diagnose the disease and discuss about the choices!

DR. rubix! Why D ?
DR. docnok Why A?
and DR. aknz Why C?
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  #6  
Old 09-30-2011
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Quote:
Originally Posted by m82_ghasemi View Post
Colleagues!!!
Let's first diagnose the disease and discuss about the choices!

DR. rubix! Why D ?
DR. docnok Why A?
and DR. aknz Why C?
Dx is multiple myeloma.

a)The lytic lesions in bone scan could be due to increased levels of osteoclast-activating factor (as myeloma cells release IL-1; osteoclast-activating factor ).

b) The ESR may be increased in this patient.(hypergammaglobulinemia causes roulex formation in peripheral blood)

c) The tumor cells produce massive quantities of different and multiple immunoglobulin molecules that are demonstrable as several narrow serum bands in electrophoresis (there is M spike,that is single spike,no multiple narrow bands).

D) Densitometry could show a sharp spike referred to an M protein.

e)The patient has a malignant plasma cell tumor with possible renal involvement.(BJ proteins damage the tubular epithelium,metastatic calcification of tubular basement membranes,as blood calcium level is high due to lytic bone lesions---renal failure is second most coommon cause of death in multiple myeloma,infection is first most common cause).

So I think,C is not correct ???
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  #7  
Old 10-01-2011
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Quote:
Originally Posted by aknz View Post
Dx is multiple myeloma.

a)The lytic lesions in bone scan could be due to increased levels of osteoclast-activating factor (as myeloma cells release IL-1; osteoclast-activating factor ).

b) The ESR may be increased in this patient.(hypergammaglobulinemia causes roulex formation in peripheral blood)

c) The tumor cells produce massive quantities of different and multiple immunoglobulin molecules that are demonstrable as several narrow serum bands in electrophoresis (there is M spike,that is single spike,no multiple narrow bands).

D) Densitometry could show a sharp spike referred to an M protein.

e)The patient has a malignant plasma cell tumor with possible renal involvement.(BJ proteins damage the tubular epithelium,metastatic calcification of tubular basement membranes,as blood calcium level is high due to lytic bone lesions---renal failure is second most coommon cause of death in multiple myeloma,infection is first most common cause).

So I think,C is not correct ???

Aknz i thought it was multiple myeloma too but it saysQuantitative immunoglobulin studies revealed hypogammaglobulinemia with a serum IgG value of 456 mg/dL (normal, 700 to 1,700 mg/dL), IgA of 15 mg/dL (normal, 70 to 350 mg/dL), and IgM of 19 mg/dL (normal, 50 to 300 mg/dL).

so couldd it be multiple myeloma? i m confused...
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  #8  
Old 10-01-2011
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Dude I am in a fix the disease described is most near the multiple myeloma but then hypogammaglobulinemia

But i will go with D as the answer as Densitometry shouldnt show a sharp spike referred to an M protein as there is hypogammaglobulinemia.
But whats the diagnosis
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  #9  
Old 10-01-2011
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yikes! I think it's C.It's not always IgG that's raised in Multiple Myeloma.It's USUALLY IgG.It can include IgA too..well this is confusing but I'll go with C.
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  #10  
Old 10-01-2011
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Correct Answer Answer

Quote:
Originally Posted by aknz View Post
Dx is multiple myeloma.

a)The lytic lesions in bone scan could be due to increased levels of osteoclast-activating factor (as myeloma cells release IL-1; osteoclast-activating factor ).

b) The ESR may be increased in this patient.(hypergammaglobulinemia causes roulex formation in peripheral blood)

c) The tumor cells produce massive quantities of different and multiple immunoglobulin molecules that are demonstrable as several narrow serum bands in electrophoresis (there is M spike,that is single spike,no multiple narrow bands).

D) Densitometry could show a sharp spike referred to an M protein.

e)The patient has a malignant plasma cell tumor with possible renal involvement.(BJ proteins damage the tubular epithelium,metastatic calcification of tubular basement membranes,as blood calcium level is high due to lytic bone lesions---renal failure is second most coommon cause of death in multiple myeloma,infection is first most common cause).

So I think,C is not correct ???
I think both C and D could be correct answers, But C could be the choice, as the spike should be identical not multiple and different. I am agree with aknz.

However, this could a case of nonsecretory Multiple Myeloma (NSMM). The disease is characterised by the absence of monoclonal proteins in serum and urine using electrophoretic tests. Nevertheless, monoclonal proteins can usually be demonstrated in the bone marrow plasma cells. Using high sensitivity tests such as isoelectric focusing, monoclonal proteins have been detected in the sera of some patients. Other patients have tumour cells that produce but do not secrete monoclonal immunoglobulins into the blood. Finally, 10-15% of NSMM patients are true “non-producers”. From a logical standpoint, such patients cannot be producing significant amounts of intact monoclonal immunoglobulins. IgG molecules accumulate in serum with a half-life of 3-4 weeks so production from even small clones of plasma cells is visible as monoclonal bands on serum protein electrophoresis gels.


Ref:
http://www.medscape.com/viewarticle/439452_2
http://www.wikilite.com/wiki/index.p...oma_%28NSMM%29
http://www.scribd.com/doc/55627553/2...t-Chain-Lambda
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  #11  
Old 10-01-2011
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so you mean the answer is C???
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  #12  
Old 10-01-2011
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Quote:
Originally Posted by doc Mm View Post
so you mean the answer is C???
Yes, C would be the answer
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