A 63 year old woman presents with 'aches and pains' in her knees, shoulders, and lower back for 3 months, in association with worsening fatigability. She has also lost weight during this time period, although the extent has not been measured. Her medical, surgical, and family histories are unremarkable, and she is not on any medications. She does not smoke, drinks only socially, and is on a normal diet. Her complete blood count is significant for a Hb of 9.5 g/dL, WBC of 3,800/mm3, and a platelet count of 115,000/mm3. A follow up peripheral blood picture reveals a normocytic, normochromic anemia with marked rouleaux formation. Her ESR is 89 mm/1hr.
Albumin: 4.1 g/dL (3.9-5.0) Total bilirubin 1.2mg/dL (0.2-1.9) ALP 160 IU/L (44-147) ALT: 34 IU/L (10-40) AST: 22 IU/L (10-34) BUN 20 mg/dL (7-20) Creatinine 1.0 mg/dL (0.7-1.3) Total protein 9.1 g/dL (6.0-8.3) Calcium: 11.6 mg/dL (8.5-10.2) Chloride 98 mmol/L (96-106) Potassium 4.1mEq/L (3.7-5.2) Sodium 141mEq/L (136-144) Glucose 93 mg/dL (70-100)
The skeletal survey reveals the presence of mild generalized osteopenia. There are no obvious lytic or sclerotic lesions, or fractures.
Serum Protein Electrophoresis: There is an M protein spike approximating to 48 g/L Immunofixation Electrophoresis: There is a monoclonal IgG protein spike, with a concentration of 47.2 g/L (0.61-3.56) Serum Immunoglobulin Free Light Chain (FLC) ratio: 7 (0.26-1.65)
The bone marrow biopsy reveals multiple sheets of plasma cells infiltrating the bone marrow; these amount to approximately 40% of the total cell population. Flowcytometry shows the plasma cells to be clonal in nature.