“CRAB” Findings in a Patient With Fatigue and Poor Appetite

Introduction

Patient

52-year-old African-American female.Chief Complaint

None; the patient was seen for follow-up of a recent stem cell transplant. The patient denied any major symptoms (eg, bone pain, poor appetite); however, she reported minimal fatigue and poor appetite that had only recently returned to normal.History of Present Illness

Two years prior to this most recent clinic visit, the patient had presented to the emergency department with flu-like symptoms and was found to have normocytic/normochromic anemia. The work-up that followed included serum (SPE) and urine (UPE) protein electrophoresis, immunofixation electrophoresis (IFE), a bone marrow biopsy and examination, and imaging studies of the axial skeleton. SPE revealed the presence of an M-spike in the gamma-region of the gel at a concentration of 6.4 g/dL. IFE, performed on the patient's serum, demonstrated the presence of an IgG kappa monoclonal immunoglobulin (Figure 1A). SPE of a sample from the patient's 24-hour urine collection demonstrated an M-spike, subsequently identified by IFE as IgG kappa. Microscopic examination of the patient's stained bone marrow biopsy demonstrated the presence of aberrant plasma cells constituting 64% of all cells observed in the bone marrow. Imaging studies of her axial skeleton revealed lytic lesions in both humeri and femurs, and in the skull, a compression fracture of the T12 vertebra, and a plasmacytoma in her left-side sixth rib. Laboratory testing revealed normal serum electrolytes, calcium, and creatinine levels. The patient started a prolonged chemotherapeutic regimen that included 3 cycles of vincristine, adriamycin, and dexamethasone (VAD), combination therapy with Thalidomide and Decadron, and Decadron maintenance therapy. Each regimen provided only a short-term reduction in the size of her serum Mspike and in her urine free light chain excretion rate. As a prelude to an autologous stem cell transplant, the patient underwent a repeat bone marrow biopsy, SPE, and UPE. The bone marrow biopsy demonstrated 27% aberrant plasma cells, while the SPE again showed an M-spike consistent with IgG kappa (0.38 g/dL); however, the UPE of a sample from a 24-hour urine collection was negative for any intact or free light chain immunoglobulins (data not shown). The patient underwent stem cell mobilization followed by bone marrow myeloablation using high-dose melphalan therapy and stem cell transfusion. She tolerated the procedure well, requiring only administration of packed red blood cells and platelets to maintain an adequate cell count of these formed elements while engraftment was occurring.

Figure 1.  (click image to zoom)

Patient's prior (A) and most recent (B) SPEP (top panel), densitometric tracing/report (middle panel), and IFE (bottom panel), demonstrating the presence of an M-spike in the gamma-region (A; top and middle panels) of the IgG kappa type (A; bottom panel), and the presence of M-spikes in the gamma-region (B; top and middle panels) consisting of the IgG kappa (2 distinct subypes), IgG lambda, and free lambda light chain types (B, bottom panel). IFE, immunofixation electrophoresis; ELP, electrophoresis lane; G, immunoglobulin G (IgG) antiserum lane; A, immunoglobulin A (IgA) antiserum lane; immunoglobulin M (IgM) antiserum lane; k, free kappa light chain antiserum lane; L, free lambda light chain antiserum lane.      

Past Medical History

Hypertension, community-acquired pneumonia, and hip repair with insertion of bilateral intramedullary nails. The patient had no known drug allergies and was currently taking: Bactrim DS (1 tablet po bid every Saturday and Sunday); Acyclovir (400 mg bid); Protonix (40 mg qd); Norvasc (5 mg qd); potassium chloride (20 mEq qd).Family/Social History

The patient's father died of colon cancer; she had no family history of any hematologic malignancies. She denied use of alcohol, tobacco, or drugs of abuse.Physical Examination

The patient appeared comfortable and in no acute distress. No abnormal findings were noted on complete physical examination.Principal Laboratory Findings, Post-Stem Cell Transplant

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Lab Med.  2005;36(8):482-485.  ©2005 American Society for Clinical Pathology
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