FOCUS SAS Training Day Leeds Dr. Joanna Sheldon Protein Reference Unit, St. George’s 1 Questions and Cases 1 List five disorders that are associated with the presence of monoclonal immunoglobulins? 2 What is the electrophoretic mobility of haemoglobin and fibrinogen on agarose pH 8.6 or comparable CZE? 3 What are the two major sites of production of the plasma proteins? 4 What are the half-lives of IgG, IgA and IgM. What is special about IgG? 5 What results need urgent action? 6 Which antibody is the most important and why? 7 What is the approx. % of BJP myeloma? 8 Where are the genes controlling immunoglobulin production, what is the order or rearrangement and what is the order of heavy chains? 9 What concentrations of fibrinogen and alpha-1 antitrypsin can be seen in inflammation? 10 What factors determine the concentration of an analyte? 11 List the main proteins in each zone on the 2 electrophoresis. 12 Which EP patterns should you immunofix? 13 What is di-thio-threitol and why do we use it? 14 What are the main proteins seen in a glomerular proteinuria? 15 Where can paraproteins or BJP appear on the serum or urine protein electrophoresis? 16 What are the possible reasons for finding monoclonal light chain only on serum immunofixation? 17 What are the possible reasons for finding heavy chain only on serum immunofixation? 18 What electrophoresis pattern would you expect in acute inflammation? 19 Are measurements of IgG, IgA and IgM traceable and if they are, what to? 20 Which is the most common antibody deficiency? 3 Write interpretative comments for the following CZE separations from adult patients. Some also show the serum immunofixations. 21. TP = 93g/L, IgG = 38.0 IgA = 0.7 IgM =1.6 22. IgG = 4.9 IgA = 0.9 IgM =0.5 23. IgG = 21.4 IgA = 6.9 IgM =2.5 24. IgG = 21.3 IgA = 3.1 IgM =0.5 4 25. IgG = 8.0 IgA = 0.8 IgM =0.5 26. IgG = 9.5 IgA = 6.3 IgM =1.9 27. IgG = 17.6 IgA = 2.6 IgM =0.8 28. Total protein = 111g/L (60-80) IgG = 72.5g/L (6-16) IgA = 1.0g/L (0.8-4) IgM = 9.8g/L (0.5-2.0) 5 29. 44 year old woman complaining of tiredness IgG = 8.0, IgA = 0.8 IgM =0.5 Urine total protein 0.4g/L Your comments and actions 6 30. The patient is a 54 year old man. Pulmonary oedema, AKI Immunoglobulin G 7.0 g/l ( 6.0 to 16.0 ) Auth Immunoglobulin A 3.8 g/L ( 0.8 to 4.0 ) Auth Immunoglobulin M 0.1 g/l ( 0.5 to 2.0 ) Auth Your comments and actions 7 31. The patient is a 49 year old woman post PBSCT. Total Protein 78 g/L ( 60 to 80 ) Auth Immunoglobulin G 14.3 g/l ( 6.0 to 16.0 ) Auth Immunoglobulin A 3.5 g/L ( 0.8 to 4.0 ) Auth Immunoglobulin M 1.7 g/l ( 0.5 to 2.0 ) Auth Your comments and actions 8 32. 72 year old female, known myeloma on treatment. No obvious paraprotein detected 35g/L IgA lambda paraprotein. Small IgG kappa paraprotein (seen since previous November) What are the possible causes of these patterns and the changes if pattern and what actions will you take? 9 33. 68 year old man – stroke investigation Total Protein 68 g/L ( 60 to 80 ) Auth Immunoglobulin G 11.3 g/l ( 6.0 to 16.0 ) Auth Immunoglobulin A 2.2 g/L ( 0.8 to 4.0 ) Auth Immunoglobulin M 0.6 g/l ( 0.5 to 2.0 ) Auth CZE and immunoglobulins double checked from primary tube Serum Agarose gel Serum protein electrophoresis immunofixation electrophoresis on CZE 72 hours later Your comments 10 34. Look at the results below for a patient with an IgG paraprotein. The graph shows the concentration of paraprotein for each serum sample received. Indicate at which points you would have contacted the requesting clinician and why. Your comments 11 35. 75 year old man - ? myeloma Total Protein 72 g/L ( 60 to 80 ) Auth Immunoglobulin G 7.5 g/l ( 6.0 to 16.0 ) Auth Immunoglobulin A 0.9 g/L ( 0.8 to 4.0 ) Auth Immunoglobulin M 0.4 g/l ( 0.5 to 2.0 ) Auth Paraprotein 4g/L Your comments and actions. What is the technique shown on the right and how does it work? 12 36. 41 year old woman in neurology being investigated for back pain. Total Protein 92 g/L ( 60 to 80 ) Auth Immunoglobulin G 37.5 g/l ( 6.0 to 16.0 ) Auth Immunoglobulin A 0.2 g/L ( 0.8 to 4.0 ) Auth Immunoglobulin M 0.2 g/l ( 0.5 to 2.0 ) Auth Paraprotein 24g/L Urine total protein = 1.1g/L Serum immunofixation Urine immunofixation Your comments and actions 13 37. 83 year old man with proteinuria (0.4g/L) and slight polyclonally raised IgG and IgA in the serum Your comments and actions 14 15 38. 54 year old female with a rash – complex medical and social history. Total Protein 92 g/L ( 60 to 80 ) Auth Immunoglobulin G 39.1 g/l ( 6.0 to 16.0 ) Auth Immunoglobulin A 1.1 g/L ( 0.8 to 4.0 ) Auth Immunoglobulin M 0.1 g/l ( 0.5 to 2.0 ) Auth Your comments and actions Paraprotein 21g/L 16 17 39. 37 year old man with spleonmegaly Immunoglobulin G 11.5 g/l ( 6.0 to 16.0) Auth Immunoglobulin A 0.7 g/L ( 0.8 to 4.0) Auth Immunoglobulin M 13.3 g/l ( 0.5 to 2.0) Auth IgM kappa paraprotein 6g/L. Your comments and actions 18 19 .