You Make the Call
Each month in “You Make the Call,” we’ll pick a challenging clinical question
submitted through the Consult-a-Colleague program and post the expert’s
response. But, what would YOU do? We’ll also pose a submitted question
and ask you to send your responses. See how your answer matches up to the
experts’ in the next print issue.
This month, Robert A. Kyle, MD, answers a question about the “faint monoclonal band” of IgG kappa or IgG lambda in a dense polyclonal background.
Clinical Dilemma:
Consult a Colleague
Through ASH
Consult a Colleague is a service for ASH
members that helps facilitate the exchange of information between hematologists and their peers. ASH members
can seek consultation on clinical cases
from qualified experts in 11 categories:
• Anemias
What is your approach to a patient who is referred for an immunofixation showing a “faint band” of monoclonal IgG
kappa or IgG lambda in a dense polyclonal background with or without an increase of that involved heavy chain?
• Hematopoietic cell
transplantation
• Hemoglobinopathies
• Hemostasis/thrombosis
• Lymphomas
Experts Make the Call
• Lymphoproliferative disorders
Robert A. Kyle, MD
Professor of Laboratory Medicine & Pathology
Professor of Medicine
Mayo Clinic
Rochester, Minnesota
• Multiple myeloma & Waldenström
macroglobulinemia
• Leukemias
• Myeloproliferative Disorders
• Myelodysplastic Syndromes
• Thrombocytopenias
In the case of the “faint band” of monoclonal IgG kappa
or IgG lambda in a dense polyclonal background, the
first thing to do is determine the size of the polyclonal
gamma component.
If it is increased, I would not be concerned about
the faint band and simply follow with a repeat electrophoresis and immunofixation in six months. The small
monoclonal protein may disappear or another small
monoclonal protein may appear.
If it persists and is still stable, I would simply repeat
the tests at annual intervals. Further evaluation such as
bone marrow examination, skeletal x-rays, etc. are not
necessary.
As you know, patients with a polyclonal increase in
immunoglobulins have an inflammatory or reactive process. The most common causes for these processes in patients
living in the United States today are connective tissue disorders or chronic liver disease, whereas in other parts of the
world tuberculosis and other infectious diseases may be major causes.
DISCLAIMER: ASH does not recommend or endorse any specific tests, physicians, products, procedures, or opinions, and
disclaims any representation, warranty, or guaranty as to the same. Reliance on any information provided in this article is
solely at your own risk.
Assigned volunteers (“colleagues”) will
respond to inquiries within two business
days (either by email or phone).
Have a puzzling clinical dilemma?
Submit a question, and read more
about Consult-a-Colleague volunteers at
hematology.org/Clinicians/Consult.aspx
or scan the QR code.
*If you have a request related to a
hematologic disorder not listed here, please
email your recommendation to ashconsult@
hematology.org so it can be considered for
addition in the future.
Next Month’s Clinical Dilemma:
The patient is a 73-year-old man with
blastic plasmacytoid dendritic cell
neoplasm and a long history of anemia.
A bone marrow biopsy three years ago
showed only iron deficiency and a gastrointestinal evaluation was unremarkable.
The patient received iron replacement
54
ASH Clinical News
therapy, but his anemia never improved.
He now presents with purple skin lesions.
A biopsy showed blastic plasmacytoid
dendritic cell neoplasm, and a bone marrow biopsy showed very cellular bone
marrow with 60 to 70 percent blastic plasmacytoid dendritic cell neoplasm. Results
from a cytogenetic analysis are pending.
Meanwhile, he has been relatively asymptomatic. He is active and healthy and his
blood count has been stable for the last
three years (white blood cell count is 3.3 x
109/L, hemoglobin count is 10.3 g/dl, and
platelet count is 135 x 109/L). He is worried
about toxicities with acute lymphocytic
leukemia–type treatment. How would you
treat this patient? What result can you
expect from treatment?
How would you respond? Email us at
[email protected].
September 2015