Contributed by Jennifer Picarsic, MD and Dimitry Gutkin, MD, PhD
A 74-year-old African-American male veteran, with a past medical history of hypertension and DJD, presented to his primary care physician with a self-report of a 20-pound weight loss and fatigue over a 6-month period. His review of symptoms was significant for alcohol abuse, previous history of multiple sexual partners, and nonspecific joint pain. He had no complaints of fever or night sweats and had previously tested negative for HIV, on multiple occasions. Medications include furosemide, hydrochlorothiazide, metoprolol, lisinopril, oxybutynin, and aspirin. Physical exam showed a blood pressure of 142/52, pulse of 72, but no focal exam findings. Initial laboratory studies revealed a normocytic, normochromic anemia (Hb/Hct: 10.2 g/dL/29.2%, MCV 89.3 fl) and a mild leukopenia (WBC 3.8 x 109/L with a normal differential), and normal platelet count of 213,000. Electrolytes included an elevated creatinine of 1.4 (baseline 1.2) with normal BUN 12, calcium 9.0 mg/dL, albumin 3.8 g/dL, and alkaline phosphatase 43 IU/L. Further studies were all within normal limits: B12, folate, iron studies (Fe 65 µg/dL, TIBC 285 µg/dL, and percent saturation 23%), haptoglobin, erythropoietin, ESR, RF, and PSA. Testing for anti-nuclear antibodies and hepatitis C antibody testing were both negative. Computed tomography (CT) imaging of the chest, abdomen, and pelvis showed no evidence of lymphoma or primary/metastatic neoplasm, with a mildly enlarged prostate, small bilateral renal cysts, and old granulomatous disease of the left upper lung lobe. Colonoscopy had a single 2 mm tubular adenoma that was removed.
Given his anemia and leukopenia with unintentional weight loss and non-specific laboratory findings, a serum protein electrophoresis (SPEP) was performed (9/2006).
Figure 1. Serum Protein Electrophoresis (Patient's sample is in Lane 6).
Question: What is concerning in lane 6? [ see Answer ]
Question: What is the differential diagnosis of a beta zone elevation? [ see Answer ]
Question: What further follow-up testing should be performed? [ see Answer ]
Question: What is the diagnosis? [ see Answer ]