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Old 01-25-2013
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Blood Large Plasma Cells in Peripheral Smear

A 53-year-old woman presents with diffuse back and rib pain that is worsened with movement. She states her periods have recently stopped, but denies experiencing hot flashes or other menopausal symptoms. She also notes a 6.8-kg (15-lb) weight gain over the past 3–4 months. On further questioning she states she has noted tingling in her fingers and toes for the past 7 months, and has recently begun tripping frequently and having trouble opening doors and buttoning her shirts. Physical examination reveals diffuse lymphadenopathy and abdominal examination reveals hepatomegaly.
Her skin is warm and dry; hyperpigmentation is noted in the regions of the neck and shoulders, and her digits are noted to be clubbed. Laboratory testing and peripheral blood smear results reveal large numbers of plasma cells; additional laboratory findings are:
WBC count: 13,000/mm3
Hemoglobin: 9.8 g/dL
Platelet count: 340,000/mm3
Erythrocyte sedimentation rate: 64 mm/hr
Blood urea nitrogen: 35 mg/dL
Creatinine: 2.1 mg/dL
Thyroid-stimulating hormone: 25 U/mL
Blood glucose level: 384 mg/dL
Ca2+: 15.4 mg/dL
Which of the following is most likely to confirm the patient’s underlying diagnosis?

(A) Complete thyroid evaluation
(B) Dexamethasone suppression test
(C) Hemoglobin A1c
(D) Pulse oximetry
(E) Urine and serum protein electrophoresis
(F) WBC differential
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Old 01-25-2013
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(E) Urine and serum protein electrophoresis
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(E) Urine and serum protein electrophoresis
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Old 01-26-2013
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The correct answer is E. This patient is presenting with POEMS syndrome, a constellation of symptoms associated with osteosclerotic multiple myeloma. Symptoms include Polyneuropathy, Organomegaly, Endocrinopathy, Multiple myeloma, and Skin changes. Polyneuropathies are generally progressive sensorimotor deficits. Hepatosplenomegaly is generally seen, in contrast to other myeloma patients. Endocrine manifestations include retamenorrhea, diabetes mellitus, hypothyroidism, and adrenal insuffi ciency. Skin changes are diverse, but may include hyperpigmentation, hypertrichosis, thickening, and digital clubbing. Although this patient’s symptoms seem unrelated, her peripheral blood smear demonstrates a large number of plasma cells, as are seen in multiple myeloma. In addition, her laboratory work reveals anemia, hyperuricemia, and hypercalcemia, all consistent with a diagnosis of multiple myeloma. This diagnosiscan be confirmed by the presence of an M spike on protein electrophoresis of urine and serum.
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