CASE REPORT a Case of Multiple Myeloma with Unusual Serum

Introduction segments during the performance of activities. Acquired brain injuries, such as Thus, the rehabilitation of children with mild hypoxic-ischemic lesions up to the age of three, motor impairment of the hemiplegic type may are among the ten main causes of spastic prove to be especially challenging to therapists, hemiplegic cerebral palsy (CP). Although it requiring profound technical knowledge and does not severely impair functionality in creativity. children, hemiplegic motor impairment The progression of the therapy in these children produces neuromotor alterations that cause is often compromised by the difficulty in finding precision deficits in movement performance and tasks that motivate them, while at the same time deficits in postural control, which is responsible showing therapeutic efficacy. for the stability and alignment between the body Developmental therapy allows the child with

and nervous system are maturing in the presence the human nervous system when damaged has of the damage and this cannot take place in a powers of compensation. In addition, the baby vacuum. The way the baby is handled and the and young child are still maturing and dormant mild motor impairment and high levels of temporal, posterior temporal and occipital attitudes that surround the baby influence how abilities can be activated. In cerebral palsy there functionality to perform tasks close to those regions. MRI of brain was advised. the maturation expresses itself in the subsequent is a potential for abnormal patterns of movement performed in their daily routine, facilitating the Developmental Therapy (motor therapy, child’s and adult’s ultimate function. and posture to become habitual and deformities transposition of the motor learning generated stimulation program, visual stimulation) is Although the motor delay and dysfunctions are can occur and become fixed. Prevention of during therapy and leading to measurable continue with regular follow up for 14 days the main problems in the cerebral palsies there is deformities is possible to a large degree and functional gains, increasing the social interval and psychological assessment the possibility of other handicaps. The brain often completely with early treatment. If integration to the environment that surrounds (BSID-III) is done. These assessment was damage itself can be diffuse enough to affect deformities are allowed to develop, then them. carried out based on observation during speech and hearing, vision, perceptual function, secondary deformities may also be promoted in administering BSID-III edition. Bayley Scales Case History mental ability and general behaviour. Epilepsy other parts of the child’s body. This handicaps of Infant Development third Edition is a A 9 months old male child came to the Child may occur. There may also be other associated him even more. standardized psychometric test for measuring development center of Apollo Hospitals Dhaka handicaps which are due to lack of motor Early treatment also decreases the associated children’s cognitive, receptive communication, with complaints of unable to sit from lying experiences in physically disabled children. handicaps which need specific therapy. The expressive communication, fine motor, gross positions and less interaction with surroundings. Lack of motor exploration affects development associated handicaps have also been known to motor, socio emotional, and adaptive behaviour Child was delivered at full term by caesarean of sensations, perceptions, mental abilities and become more severe than the motor problems. ability. Throughout this assessment we found his section with appropriate birth weight. Child was speech. Emotional and social skills are also Handicaps interact with one another and the Cognitive domain: Significantly delayed admitted in NICU up to his seven days of age hampered. Patients-child’s interaction is not cerebral palsied child must be considered as a intellectual functioning level, Language due to peri natal asphyxia stage- II. There was always easy and may create emotional multiple handicapped child. Not all cerebral (receptive and expressive) domain: history of delayed milestone and difficulties in problems. palsied children have multiple handicaps, but deglutition of semi-solid food without drooling. Significantly delayed, Motor (Fine and gross) Early therapy is advisable to minimize the today there seem to be increasing numbers domain: Significantly delayed. On examination by Rapid neurodevelopmental degree of motor handicap and of the secondary referred for therapy who are mentally and in assessment-Gross Motor: Couldn’t sideline in After 4th follow up in 14 days interval Rapid development handicaps. multiple ways handicapped. right and left side from lying position, Fine Neurodevelopmental assessment was done There are still medical practitioners who hesitate References Motor-No reaching and digital grasp with left whereas Gross Motor - could sit from lying about the referral of cerebral palsied babies for 1.Khan NZ. Best resource use for disabled children. and right hand, Vision- Only could fix and without support, Fine Motor- could transfer World Health Forum.1998:19(1):47-58. therapy. This may be due to the fact that some 2. Khan NZ, Muslima H, Parveen M. Neuro- follow adults face, couldn’t fix and follow object in both hands but radial digital grasp in babies improve and even become normal developmental outcomes of preterm infants in spinning bright ball from 12.5cm. right hand and digital grasp in left hand, Bangladesh. Pediatrics. 2006;118(1):280-89 without any treatment. Unfortunately we do not 3. Zaman SZ, Khan NZ, Islam S. Validity of the “Ten Hearing-Could locate voice at ear level with Cognition- could shake rattle and had yet know definitely which neurologically Questions” for screening serious childhood disability: minimum sound. Speech- Only had vocalization pat-a-cake. Vision - could fix and follow shiny results from urban Bangladesh. Int J Epidemiol. damaged babies will become cerebral palsied (ghh, ooh,eeh), Cognition- He had no social bright object, Speech - babbling was started. 1990;19(3):613-20. and which will not. It is best to give each child 4. Banu SH, Tanaka Y, Selim AF, Khan NZ. Evaluation smile. Discussion of neurodevelopmental status after an early stimulation the benefit of developmental therapy, and his program for babies at risk for developmental delay. Nervous system examination- Tone was The cerebral palsies are a group of conditions parents practical guidance in his daily care, by a Poster presentation at: 2nd International Perinatal increased in right side, Deep tendon reflexes due to non-progressive damage to the brain therapist who can also detect motor patterns of Congress of the Bangladesh Perinatal Society: November 21-2. 2008. Dhaka Bangladesh. were exaggerated on the right side. before, during or after birth. Although the brain cerebral palsy. Every chance for the baby’s 5.Ahmed AS, Muslima H, Anwar KS. Retinopathy of EEG was suggestive of abnormal record due to damage itself does not change nor is it curable, damaged nervous system to develop is offered prematurity in Bangladeshi neonates. J Trop Pediatr. 2008;54(5):333-39. presence of sharp transients over both anterior the symptoms may change with time. The brain by early treatment of this kind. We know that 6. Durkin MS, Khan NZ, Davidson LL. Validity of the

CASE REPORT ten questions screen for childhood disability: results from after acquired brain injury: current and emerging A Case of Multiple Myeloma with Unusual Serum Protein Electrophoresis population-based studies in Bangladesh, Jamaica and approaches. Pediatr Neurol. 2012;46:339–44. [PubMed] Pakistan. Epidemiology. 1994;5(3):283-89. 14. Rodrigues SD, Ciasca SM, Guimarães IE, Elias KM, 1 2 7. Bobath K.1980. A neurophysiological basis for the Oliveira CC, Moura-Ribeiro MV. Does stroke impair Nargis W , Ibrahim M treatment of cerebral palsy. William Heinemann Medical learning in children? Stroke Res Treat [serial on the Books, London. Internet]. 2011;2011:1-6. 8. Gillette H.E.1969. Systems of therapy in cerebral http://www.hindawi.com/journals/srt/2011/369836/cta/ Abstract palsy. Charles C.Thomas, Springfield, Illinois. 15. Barela JA, Focks GM, Hilgeholt T, Barela AM, 9. Pearson H.P. & William S C.E. eds. 1978. Physical Carvalho R de P, Savelsbergh GJ. Perception-action and Monoclonal gammopathy is a group of B-cell disorders resulting in the secretion of a specific and therapy services in the developmental disabilities. adaptation in postural control of children and adolescents unique monoclonal immunoglobulin (M-component); best detecting with high resolution agarose Charles C. Thomas, Springfield, Illinois. with cerebral palsy. Res Dev Disabil. 2011;32:2075-83. gel electrophoresis. An M-protein is usually visible as a localized band on agarose gel 10. Bayley N. (1993) Bayley scales of infant [PubMed] development-second edition. San Antonio,TX:The 16. De Campos AC, Da Costa CS, Rocha NA. Measuring electrophoretic peak in the beta, gamma, or rarely in the alpha-2globulin region of the Psychological Corporation. changes in functional mobility in children with mild densitometer tracing. Here, we presented a multiple myeloma patient with IgA kappa paraprotein 11. Brauer,B.A.Braden,J.P.,Pollard ,R.Q, & Hardy-Braz, cerebral palsy. Devel Neurorehabil. 2011;14:140–44. showing an M spike in the alpha-2 globulin region in agarose gel electrophoresis. S.T. 1998. Deaf and hard of hearing problem. In [PubMed] J.Sandoval, C.L.Frisby, K.F.Geisinger, J.D.Scheuneman 17. Prosser LA, Lee SC, Barbe MF, VanSant AF, Lauer Key words & J.R.Grenier. eds. Test interpretation and diversity: RT. Trunk and hip muscle activity in early walkers with Multiple myeloma, protein electrophoresis achieving equity in assessment. pp 297-316. Washington, and without cerebral palsy - a frequency analysis. J DC: American Psychological Association. Electromyog Kinesiol. 2010;20:851–859. [PMC free 12.Hatton DD, Bailey DB, Burchinal MR, Ferrell KA. article][PubMed] Introduction by agarose gel electrophoresis. 1997. Developmental growth curves of preschool 18. Michalski A, Glazebrook CM, Martin AJ, Wonga Among the methods of protein electrophoresis; children with vision impairments. Child Development. WW, Kim AJ, Moody KD, et al. Assessment of the Case Report 68(5);788-806. postural control strategies used to play two Wii FitTM agarose gel electrophoresis is much more sensitive A sixty one year old woman was referred to the 13. Gordon AL, di Maggio A. Rehabilitation for children videogames. Gait Posture. 2012;6:449–453. [PubMed] than cellulose acetate method. In order to hematology clinic of Apollo Hospitals Dhaka with determine the immunoglobulin subtype and symptoms of fatigue and back pain in November ensure the presence of M-protein in all patients 2011. On physical examination, there was no with local M band detected in protein pathological finding other than paleness of the electrophoresis, serum and urine immunofixation skin and conjunctiva. procedure must surely be performed as further In the laboratory examinations performed, the investigation. M-protein is generally observed as a following values were found; erythrocyte localized band which is frequently seen on gamma sedimentation rate: 130 mm/hour, Hb- 6.2 g/dl, or beta region, it may also be seen on alpha-2 TLC-4.4 x10^9/L, PLT (plateletcount)- globulin region but this situation is very rare.1,2 160x10^9/L. S. protein electrophoresis showed Sometimes, IgG multiple myeloma may extend to monoclonal gammopathy (Fig.1). Serum the alpha-2 globulin area, because IgG M-protein Immunofixation revealed IgA, Kappa monoclonal may range from the slow gamma to the alpha-2 gammopathy with raised Beta 2 microglobulin globulin region.3 Here, we presented an adult (7369 ug/L). Creatinine clearance was found to be patient diagnosed as IgA kappa type multiple 18.1 ml/hour. Urinary system ultrasonography myeloma, who had an M band on alpha-2 globulin was normal.The bone marrow aspirate showed region on the protein electrophoresis performed infiltration with plasma

1. Associate Consultant, Dept. of Biochemistry, Uttara Adhunik Medical College & Hospital, Uttara, Dhaka 2. Consultant, Dept of Clinical Biochemistry, Apollo Hospital, Dhaka.

Pulse Volume 8 2015 77 of which is unknown. The patient was not in renal haptoglobulin constitute the alpha-2 fraction of CASE REPORT failure as evident from GFR and renal function the protein electrophoresis and the alpha-2 test. Renal failure, defined as a serum creatinine component increases as an acute phase reactant. cells by 57%. In the bidirectional cranium X-ray patient was diagnosed as Stage-IIIB multiple ≥2 mg/dl at the time of diagnosis, is seen in 21% Generally IgA, IgG and IgM proteins are not graphy, five lytic lesions, the biggest one being 5 myeloma according to Salmon-Durie staging of patients.9,10 In the patient, the M band on the α observed on the alpha-2 fractions. These proteins mm in diameter were detected. In dorsal and criteria and was planned to be treated 2 region and β region was shown to be bound to compose beta-1, beta-2, and gamma fractions.4 lumber vertebra direct X-ray graphs, collapse accordingly. IgA. The conventional technique serum However, in IgG multiple myeloma fractures were seen on L2-L3 and L4-L5. The electrophoresis is still widely used for the immunoglobulins may rarely migrate from demonstration of M-Protein in the myeloma gamma fraction to alpha-2 fraction.3 M-protein patient and it remains a gold standard. Multiple that is seen on the alpha-2 band is just reported in myeloma arises from plasma cell dyscrasia. a few numbers of IgA multiple myeloma cases in These malignant plasma cells synthesize literature. Mseddi-Hdiji et al.7 reported that in monoclonal antibody and release it to the electrophoresis that is performed by agarose gel circulation. As a result high concentration of method 78% of the 242 monoclonal gammopathy monoclonal antibodies is present in bone marrow cases had M band on gamma region whereas 22% as well as in serum.4 The circulating M-protein of the cases had band on beta region and none of may consist of an intact immunoglobulin, the the cases had it on alpha-2 region. Bakta and light chain only, or (rarely) the heavy chain only. Sutarka8 observed two seperate M bands on the Fig. 1: Serum protein electrophoresis Fig. 2: Serum immunofixation The heavy chain is from one of the five beta-2 and alpha-2 regions in the serum protein immunoglobulin classes G, A, M, D or E, while electrophoresis of a patient that they considered Discussion routine blood testing. When present, symptoms the light chain is either κ (kappa) or λ (lambda) in to have multiple myeloma. From the serum Multiple myeloma is the second most-common may be vague and similar to those of other type. It occurs as intense, narrow band most often immunofixations, these were reported to be IgM hematologic cancer, representing 1% of all conditions.6 Our case presented with fatigue and found with the gamma-globulins, then in a and IgA immunoglobulins. In our patient, the M cancer diagnoses and 2% of all cancer deaths. back pain for 2 years. diminishing frequency between γ and the band on the alpha-2 region was shown to be Multiple myeloma affects men slightly more than A myeloma diagnosis is often based on the β-globulin and rarely in the β and α2 regions. bound to IgA like a few others.9,10 So, this case women. African Americans have the highest presence of an increased number of plasma cells Generally IgA, IgG and IgM proteins are not reminds that, M band on alpha-2 region in serum reported incidence of this disease and Asians in the bone marrow and, in most cases, the observed on the α2 fractions. These proteins protein electrophoresis can rarely be seen in IgA have the lowest.5 The case presented here was of presence of excess protein (M protein) in the compose β-1, β-2, and γ fractions.5 However, in myeloma patients. a 61 year old Bangladeshi female. blood or urine. Serum electrophoresis can be IgG multiple myeloma immunoglobulins may Reference In multiple myeloma patients, mutated plasma routinely used for the diagnosis of multiple rarely migrate from γ fraction to α2 fraction.6 1. Nau KC, Lewis WD. Multiple myeloma: diagnosis and cells - otherwise known as myeloma cells - grow myeloma and is well correlated with M-protein that is seen on the α2 band is just treatment. AmFam Physician. 2008;78(7):853–59. 2. Kyle AR, Rajkumar SV, Lust AJ. Monoclonal unregulated by the processes that normally biochemical, radiological and pathological reported in a few numbers of IgA multiple gammopathy of undetermined significance and control cell division and death. By the time the findings. In our patient most of the biochemical myeloma cases. Very rarely, biclonal smoldering multiple myeloma. In: Greer JP, Foerster J, Lukens JN, Rodgers GM, Paraskevas F, Glader B, editors. disease is diagnosed, most patients have results were suggestive of the pattern found in gammopathies (accounts for 1% of all Wintrobe’s clinical hematology. Chapter 97. 11th ed. myeloma cells in multiple sites throughout the multiple myeloma. The patient was having monoclonal gammopathies) or triclonal Philadelphia: Lippincott Williams & Wilkins; 2004. p. 2566–7. bone marrow. There are often no symptoms in the normal serum calcium level at time of diagnosis. gammopathy can be observed in multiple 3. O’Connell TX, Horita TJ, Kasravi B. Understanding early stages of myeloma. In some cases, Hypercalcemia is found initially in 22–30% myeloma. and interpreting serum protein electrophoresis. Am Fam myeloma may be discovered by accident during patient with multiple myeloma7,8, the exact cause Physician. 2005;71:105-12. Ceruloplasmin, alpha-2 macroglobulin and 4. Kyle RA, Rajkumar SV. Plasma cell disorders. In:

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of which is unknown. The patient was not in renal haptoglobulin constitute the alpha-2 fraction of failure as evident from GFR and renal function the protein electrophoresis and the alpha-2 test. Renal failure, defined as a serum creatinine component increases as an acute phase reactant. cells by 57%. In the bidirectional cranium X-ray patient was diagnosed as Stage-IIIB multiple ≥2 mg/dl at the time of diagnosis, is seen in 21% Generally IgA, IgG and IgM proteins are not graphy, five lytic lesions, the biggest one being 5 myeloma according to Salmon-Durie staging of patients.9,10 In the patient, the M band on the α observed on the alpha-2 fractions. These proteins mm in diameter were detected. In dorsal and criteria and was planned to be treated 2 region and β region was shown to be bound to compose beta-1, beta-2, and gamma fractions.4 lumber vertebra direct X-ray graphs, collapse accordingly. IgA. The conventional technique serum However, in IgG multiple myeloma fractures were seen on L2-L3 and L4-L5. The electrophoresis is still widely used for the immunoglobulins may rarely migrate from demonstration of M-Protein in the myeloma gamma fraction to alpha-2 fraction.3 M-protein patient and it remains a gold standard. Multiple that is seen on the alpha-2 band is just reported in myeloma arises from plasma cell dyscrasia. a few numbers of IgA multiple myeloma cases in These malignant plasma cells synthesize literature. Mseddi-Hdiji et al.7 reported that in monoclonal antibody and release it to the electrophoresis that is performed by agarose gel circulation. As a result high concentration of method 78% of the 242 monoclonal gammopathy monoclonal antibodies is present in bone marrow cases had M band on gamma region whereas 22% as well as in serum.4 The circulating M-protein of the cases had band on beta region and none of may consist of an intact immunoglobulin, the the cases had it on alpha-2 region. Bakta and light chain only, or (rarely) the heavy chain only. Sutarka8 observed two seperate M bands on the The heavy chain is from one of the five beta-2 and alpha-2 regions in the serum protein immunoglobulin classes G, A, M, D or E, while electrophoresis of a patient that they considered Discussion routine blood testing. When present, symptoms the light chain is either κ (kappa) or λ (lambda) in to have multiple myeloma. From the serum Multiple myeloma is the second most-common may be vague and similar to those of other type. It occurs as intense, narrow band most often immunofixations, these were reported to be IgM hematologic cancer, representing 1% of all conditions.6 Our case presented with fatigue and found with the gamma-globulins, then in a and IgA immunoglobulins. In our patient, the M cancer diagnoses and 2% of all cancer deaths. back pain for 2 years. diminishing frequency between γ and the band on the alpha-2 region was shown to be Multiple myeloma affects men slightly more than A myeloma diagnosis is often based on the β-globulin and rarely in the β and α2 regions. bound to IgA like a few others.9,10 So, this case women. African Americans have the highest presence of an increased number of plasma cells Generally IgA, IgG and IgM proteins are not reminds that, M band on alpha-2 region in serum reported incidence of this disease and Asians in the bone marrow and, in most cases, the observed on the α2 fractions. These proteins protein electrophoresis can rarely be seen in IgA have the lowest.5 The case presented here was of presence of excess protein (M protein) in the compose β-1, β-2, and γ fractions.5 However, in myeloma patients. a 61 year old Bangladeshi female. blood or urine. Serum electrophoresis can be IgG multiple myeloma immunoglobulins may Reference In multiple myeloma patients, mutated plasma routinely used for the diagnosis of multiple rarely migrate from γ fraction to α2 fraction.6 1. Nau KC, Lewis WD. Multiple myeloma: diagnosis and cells - otherwise known as myeloma cells - grow myeloma and is well correlated with M-protein that is seen on the α2 band is just treatment. AmFam Physician. 2008;78(7):853–59. 2. Kyle AR, Rajkumar SV, Lust AJ. Monoclonal unregulated by the processes that normally biochemical, radiological and pathological reported in a few numbers of IgA multiple gammopathy of undetermined significance and control cell division and death. By the time the findings. In our patient most of the biochemical myeloma cases. Very rarely, biclonal smoldering multiple myeloma. In: Greer JP, Foerster J, Lukens JN, Rodgers GM, Paraskevas F, Glader B, editors. disease is diagnosed, most patients have results were suggestive of the pattern found in gammopathies (accounts for 1% of all Wintrobe’s clinical hematology. Chapter 97. 11th ed. myeloma cells in multiple sites throughout the multiple myeloma. The patient was having monoclonal gammopathies) or triclonal Philadelphia: Lippincott Williams & Wilkins; 2004. p. 2566–7. bone marrow. There are often no symptoms in the normal serum calcium level at time of diagnosis. gammopathy can be observed in multiple 3. O’Connell TX, Horita TJ, Kasravi B. Understanding early stages of myeloma. In some cases, Hypercalcemia is found initially in 22–30% myeloma. and interpreting serum protein electrophoresis. Am Fam myeloma may be discovered by accident during patient with multiple myeloma7,8, the exact cause Physician. 2005;71:105-12. Ceruloplasmin, alpha-2 macroglobulin and 4. Kyle RA, Rajkumar SV. Plasma cell disorders. In:

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Goldman L, Ausiello D, editors. Cecil textbook of in Tunisia: epidemiological, immunochemical and medicine. Chapter 196. 22. Philadelphia: W. B. Saunders; etiological analysis of 288 cases. PatholBiol (Paris). 2004. pp. 1184-86. 2005;53:19-25. 5. Eleutherakis-Papaiakovou V, Bamias A, Gika D, 8. Bakta IM, Sutarka IN. Biclonalgammopathy in multiple Simeonidis A, Pouli A, Anagnostopoulos A,et.al. Greek myeloma: a case report. Gan To Kagaku Ryoho. 2000;27 Myeloma Study Group. Renal failure in multiple Suppl 2:544-8. myeloma: incidence, correlations, and prognostic 9. Yildrim ND, Ayer M, Hatipoglu E, Kucukkaya significance. Leuk Lymphoma. 2007;48(2):337-341. doi: RD,Yenrel MN, Nalcaci M. Atypical M-protein 10.1080/10428190601126602. localization in protein electrophoresis in a patient with 6. Bakkus MH, Schots R, Gomez La Fuente PB. Clonally multiple myeloma. TrakyaUniv Tip FakDerg. related IgA- and IgE-secreting plasma cells in a myeloma 2008;25(1):56-9. patient. Eur J Haematol. 2000;65:348. doi: 10. Dash NR and Mohanty B. Multiple Myeloma: A case 10.1034/j.1600-0609.2000.065005348.x. of atypical presentation on protein electrophoresis. Indian 7. Mseddi-Hdiji S, Haddouk S, Ben Ayed M, Tahri N, J ClinBiochem. Jan 2012;27(1):100-102. Elloumi M, Baklouti S, et al. Monoclonal gammapathies of which is unknown. The patient was not in renal haptoglobulin constitute the alpha-2 fraction of failure as evident from GFR and renal function the protein electrophoresis and the alpha-2 test. Renal failure, defined as a serum creatinine component increases as an acute phase reactant. cells by 57%. In the bidirectional cranium X-ray patient was diagnosed as Stage-IIIB multiple ≥2 mg/dl at the time of diagnosis, is seen in 21% Generally IgA, IgG and IgM proteins are not graphy, five lytic lesions, the biggest one being 5 myeloma according to Salmon-Durie staging of patients.9,10 In the patient, the M band on the α observed on the alpha-2 fractions. These proteins mm in diameter were detected. In dorsal and criteria and was planned to be treated 2 region and β region was shown to be bound to compose beta-1, beta-2, and gamma fractions.4 lumber vertebra direct X-ray graphs, collapse accordingly. IgA. The conventional technique serum However, in IgG multiple myeloma fractures were seen on L2-L3 and L4-L5. The electrophoresis is still widely used for the immunoglobulins may rarely migrate from demonstration of M-Protein in the myeloma gamma fraction to alpha-2 fraction.3 M-protein patient and it remains a gold standard. Multiple that is seen on the alpha-2 band is just reported in myeloma arises from plasma cell dyscrasia. a few numbers of IgA multiple myeloma cases in These malignant plasma cells synthesize literature. Mseddi-Hdiji et al.7 reported that in monoclonal antibody and release it to the electrophoresis that is performed by agarose gel circulation. As a result high concentration of method 78% of the 242 monoclonal gammopathy monoclonal antibodies is present in bone marrow cases had M band on gamma region whereas 22% as well as in serum.4 The circulating M-protein of the cases had band on beta region and none of may consist of an intact immunoglobulin, the the cases had it on alpha-2 region. Bakta and light chain only, or (rarely) the heavy chain only. Sutarka8 observed two seperate M bands on the The heavy chain is from one of the five beta-2 and alpha-2 regions in the serum protein immunoglobulin classes G, A, M, D or E, while electrophoresis of a patient that they considered Discussion routine blood testing. When present, symptoms the light chain is either κ (kappa) or λ (lambda) in to have multiple myeloma. From the serum Multiple myeloma is the second most-common may be vague and similar to those of other type. It occurs as intense, narrow band most often immunofixations, these were reported to be IgM hematologic cancer, representing 1% of all conditions.6 Our case presented with fatigue and found with the gamma-globulins, then in a and IgA immunoglobulins. In our patient, the M cancer diagnoses and 2% of all cancer deaths. back pain for 2 years. diminishing frequency between γ and the band on the alpha-2 region was shown to be Multiple myeloma affects men slightly more than A myeloma diagnosis is often based on the β-globulin and rarely in the β and α2 regions. bound to IgA like a few others.9,10 So, this case women. African Americans have the highest presence of an increased number of plasma cells Generally IgA, IgG and IgM proteins are not reminds that, M band on alpha-2 region in serum reported incidence of this disease and Asians in the bone marrow and, in most cases, the observed on the α2 fractions. These proteins protein electrophoresis can rarely be seen in IgA have the lowest.5 The case presented here was of presence of excess protein (M protein) in the compose β-1, β-2, and γ fractions.5 However, in myeloma patients. a 61 year old Bangladeshi female. blood or urine. Serum electrophoresis can be IgG multiple myeloma immunoglobulins may Reference In multiple myeloma patients, mutated plasma routinely used for the diagnosis of multiple rarely migrate from γ fraction to α2 fraction.6 1. Nau KC, Lewis WD. Multiple myeloma: diagnosis and cells - otherwise known as myeloma cells - grow myeloma and is well correlated with M-protein that is seen on the α2 band is just treatment. AmFam Physician. 2008;78(7):853–59. 2. Kyle AR, Rajkumar SV, Lust AJ. Monoclonal unregulated by the processes that normally biochemical, radiological and pathological reported in a few numbers of IgA multiple gammopathy of undetermined significance and control cell division and death. By the time the findings. In our patient most of the biochemical myeloma cases. Very rarely, biclonal smoldering multiple myeloma. In: Greer JP, Foerster J, Lukens JN, Rodgers GM, Paraskevas F, Glader B, editors. disease is diagnosed, most patients have results were suggestive of the pattern found in gammopathies (accounts for 1% of all Wintrobe’s clinical hematology. Chapter 97. 11th ed. myeloma cells in multiple sites throughout the multiple myeloma. The patient was having monoclonal gammopathies) or triclonal Philadelphia: Lippincott Williams & Wilkins; 2004. p. 2566–7. bone marrow. There are often no symptoms in the normal serum calcium level at time of diagnosis. gammopathy can be observed in multiple 3. O’Connell TX, Horita TJ, Kasravi B. Understanding early stages of myeloma. In some cases, Hypercalcemia is found initially in 22–30% myeloma. and interpreting serum protein electrophoresis. Am Fam myeloma may be discovered by accident during patient with multiple myeloma7,8, the exact cause Physician. 2005;71:105-12. Ceruloplasmin, alpha-2 macroglobulin and 4. Kyle RA, Rajkumar SV. Plasma cell disorders. In:

CASE REPORT

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