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Old 10-27-2012
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Question Large Spike in Gamma Region

A 64-year-old woman presents to her primary care physician with fatigue, weakness, and a weight loss of 4.5 kg (10 lb) in the past 4 months. Additionally, she notes that her vision has deteriorated over that time, and has had several severe nosebleeds. Physical examination demonstrates hepatosplenomegaly, and laboratory tests show an increased total protein level. Serum protein electrophoresis reveals a large spike in the gamma region. A skeletal survey is negative. Which of the following is the most likely diagnosis?

A Chronic lymphocytic leukemia
B Diabetes mellitus
C Monoclonal gammopathy of undetermined significance
D Multiple myeloma
E Waldenström's macroglobulinemia
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Old 10-27-2012
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E .. No lytic lesions , weight loss ( suggests cancer ) , hyperviscosity-eye..!!! Waldenstorm's macroglobulinemia
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Old 10-27-2012
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Default Ee

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Originally Posted by alice View Post
E .. No lytic lesions , weight loss ( suggests cancer ) , hyperviscosity-eye..!!! Waldenstorm's macroglobulinemia
Agreed.....................................
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Old 10-27-2012
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i go with waldenstorms macroglobulinemia
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Old 10-28-2012
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Default my answer :)

C Monoclonal gammopathy of undetermined significance
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  #6  
Old 10-28-2012
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Symptoms of Waldenstrom are present, but that would give us an IgM spike.The patient in the stem has an IgG spike (gamma), so most diagnosis is probably MGUS.

(I went for Waldenstrom cause of hyperviscosity symptoms and absence of lytic lesions. But then checked FA. And um. Changed my asnwer! )
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C) MGUS

thanks
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Old 10-28-2012
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Gamma region doesn't imply specific IgG I think .. The electrophoresis pattern includes both proteins( albumins and gamma globulins I.e., immunoglobulins )
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Default C Monoclonal gammopathy of undetermined significance

Quote:
Originally Posted by MedicalExaminer View Post
A 64-year-old woman presents to her primary care physician with fatigue, weakness, and a weight loss of 4.5 kg (10 lb) in the past 4 months. Additionally, she notes that her vision has deteriorated over that time, and has had several severe nosebleeds. Physical examination demonstrates hepatosplenomegaly, and laboratory tests show an increased total protein level. Serum protein electrophoresis reveals a large spike in the gamma region. A skeletal survey is negative. Which of the following is the most likely diagnosis?

A Chronic lymphocytic leukemia
B Diabetes mellitus
C Monoclonal gammopathy of undetermined significance
D Multiple myeloma
E Waldenström's macroglobulinemia
large spike in gamma region but they didn't specified IgG (multiple myeloma) or IgM (waldenstrom).
So i think C Monoclonal gammopathy of undetermined significance
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i am with E Waldenström's macroglobulinemia :sorry:
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E- waldenstrom macroglibulinemia

I don't think MGUS will have all the complications mentioned in question and it has a smaller spike
Spike in gamma region represents monoclonal spike so it could be any of the Ig
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Default errata :)

yeah, I guess the answer should be Waldenstrom - since there's hiperviscosity symptoms (eyesight), bone marrow (nosebleeds) and spleen and liver involvement.
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Default Waldenstroms

E- Gamma spike = Monoclonal spike. She also has signs of hyperviscosity (the eyesight problems). Lack of bone lesions. IgM in Waldenstroms binds to clotting factors making them unable to coagulate causing the nasal bleeding (plus the fact that there is low platelet count)

Last edited by freebielady; 10-28-2012 at 02:28 PM. Reason: Mixed up some info
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The correct answer is E. The disease that is described is Waldenström's macroglobulinemia, which is characterized by weakness, weight loss, a monoclonal M spike on serum protein electrophoresis (seen as a large spike in the gamma region), and a hyperviscosity syndrome (manifesting as nosebleeds, headaches, and vision disturbances). Hyperviscosity is caused by the large amount of IgM protein in the blood produced by a B-cell neoplasm. These large proteins interfere with microvascular and cellular processes, causing blood vessel damage, which results in headaches due to impaired cranial blood flow and in disturbances in vision due to poor ocular blood flow. Additionally, circulating IgM proteins can bind to clotting factors and inhibit them, causing increased bleeding.

Answer A is incorrect. Chronic lymphocytic leukemia (CLL) typically presents with lymphadenopathy, hepatosplenomegaly, a warm antibody autoimmune hemolytic anemia, and smudge cells in the peripheral blood. The hyperviscosity syndrome is not present in CLL.

Answer B is incorrect. Diabetes presents with nocturia, polyuria, and polydipsia. Blood tests would demonstrate increased glucose. Superficial resemblances between the hyperviscosity syndromes and diabetic retinopathy, and diabetic kidney disease with the renal insufficiency of multiple myeloma, may be misleading. However, bleeding complications due to diabetes alone would be rare.

Answer C is incorrect. Monoclonal gammopathy of undetermined significance (MGUS) is similar to the condition described above in that it, too, has a monoclonal spike. An important difference is that MGUS is asymptomatic due to a lower level of protein. Some patients may experience mild polyneuropathy, but they will not have the bone pain, renal failure, and anemia of multiple myeloma or the hyperviscosity of Waldenström's macroglobulinemia. Nonetheless, MGUS may be a premalignant lesion that can progress to multiple myeloma.

Answer D is incorrect. Multiple myeloma is similar to the condition described above and it also involves abnormal plasma cells overproducing immunoglobulin, seen as a monoclonal M spike (critical for diagnosis). However, instead of a hyperviscosity syndrome, multiple myeloma typically presents with a collection of other characteristic symptoms. These symptoms include with lytic bone lesions causing bone pain and hypercalcemia, renal insufficiency and azotemia, increased susceptibility to infection, and anemia. Additionally, one may find Bence Jones protein (Ig light chains) in the urine and a rouleaux formation of RBCs on peripheral blood smear.
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