An Unexplained Hyperphosphatemia in an Hispanic Woman , a Diagnosis Challenge

Introduction Hyperphosphatemia could be a finding in renal failure, tumor lysis syndrome, hypoparathyroidism, and ingestion of exogenous phosphate. We present the case of a woman with hyperphosphatemia in which we finally diagnosed multiple myeloma, serum phosphate level achieved normal range after chemotherapy started. Although hyperphosphatemia in multiple myeloma is a very rare finding, there are some reports. The proposed mechanisms include a large amount of paraproteins that interferes with phosphorus level determination showing a false increased level. When samples have been deproteinated before analysis, serum phosphorus level can decrease obtaining a true level. This case reminds clinicians the importance of seeking additional causes for abnormal phosphorus levels before starting treatments that could lead to hypophosphatemia. Case report An hispanic woman at the 7th decade of life that only suffered from controlled hypothyroidism, who assisted with complaints of axial pain mainly in thoracic and lumbar segments. She denied neurological and B symptoms. She had a CT scan performed and was referred to the hematology service.On clinical examination we didn't find any neurological signs, no megalies and no palpable nodes. The patient brought a CT spine scan showing thoracic images suggestive of mets with collapse of 50% in T12-L1 and a mass in S2.With these findings we decided to start intrahospitalary studies for excluding malignancy.Her relevant laboratories were: creatinine 0,7, BUN 25, Hemoglobin 9 gr/dl VCM 102 WBC 3330 Granulocytes 55% Platelet 222.000, UN 10,7, albumin 2.8, Lactate dehydrogenase 425. A series of labs seeking secondary causes of malignancy was made including plasmatic cell neoplasie.The hepatic function was normal but an unusually high Phosphorus level was detected (19,6) with normal calcemia (8.98), the tumoral biomarkers were in normal range (CEA, CA 19-9, Ca 125, AFP) and an elevated B2 microglobulin (8) was found. Additional labs included bence jones protein and PTH, both in normal range. A new Thoracic CT described mosaic infiltrates and an extensive bone involvement suggestive of lytic metastatic changes. The abdomen CT showed multiple lytic lesions in lumbo-sacral spine and pelvis, The skull radiography had lytic lesions too. The nephrology service was required by the Hyperphosphatemia and they asked about external intake of phosphorus finding that she was taking "hydrolyzed collagen", so they started iv fluid and chelators (aluminium hydroxide and no calcium chelators).Because of unresponsive hyperphosphatemia, nephrology started hemodialysis.Hematology found high IgG levels (5500) concluding the need for bone marrow studies . Finally a the bone marrow study was performed and prescribed steroids on suspicion of Multiple myeloma. Until this day the Phosphorus level still remained in high levels (17,7) despite hemodialysis sessions. The bone marrow study revealed a plasmatic cell population of 28,9% with big and abundant cytoplasm, some of them with binucleations suggestive of infiltration by plasmatic cell neoplasie. The seric electrophoresis revealed a paraprotein (seric protein of 9,3 with a monoclonal peak of gamma region of 3,4 gr/dl), the seric immunofixation was positive for a monoclonal IgG lambda component. With this report we began chemotherapy treatment for Myeloma with CyBorD regimen (Cyclophosphamide, Bortezomib, dexamethasone). After treatment was initiated, phosphorus level began to lower and achieved normal range (4.28) in the first two weeks. Then she was discharged to continue outpatient management. Nowadays she is receiving her 3rd chemotherapy cycle without complications, her phosphorus level still remains within normality. Conclusions Spurious hyperphosphatemia in patients with paraproteinemias like multiple myeloma can occur. The IgG monoclonal can interfere with the phosphomolybdate principle used in the assay of serum phosphate on most automated chemistry analysers. For labs which do not have a multilayered film technology based system, a serial dilution analysis of the suspected analyte could be performed. Disclosures No relevant conflicts of interest to declare.

Evaluation of Correlation between Serum Free Light-Chain Assay and Bone Marrow Study in Multiple Myeloma Patients

Background: Multiple myeloma is a hematologic malignancy manifested by the secretion of abnormal immunoglobulin. Different methods have been described for diagnosis and patient response to management. Serum free light-chain assay is recently approved in the diagnosis of multiple myeloma patients. This study aimed to evaluate the diagnostic accuracy of serum free light-chain assay and its agreement to bone marrow findings. Materials and Methods: Forty-six patients with the diagnosis of multiple myeloma were enrolled in the study. The patients were grouped into newly diagnosed cases (22 patients,47.8%) and known cases who were under treatment (24 patients,52.2%). Bone marrow study was done and percentage and clonal status of plasma cells were evaluated by a combination of immunohistochemistry and flow cytometry. Free light-chain assay was done in all patients and sensitivity, specificity, positive predictive value, and negative predictive value were analyzed. Results: Thirty of 46 patients showed monoclonal plasma cell infiltration and 16 patients showed polyclonal plasma cell infiltration based on bone marrow findings. An abnormal κ/λ ratio was seen in 15(68.18%) of new cases and 16(66.6%) of known cases. Sensitivity, specificity, PPV and NPV for κ⁄λ ratio were 72.73%, 46.15%, 71%, and 50%, respectively. Conclusion: In conclusion, due to high false positive and false negative results, the presence of an abnormal serum FLC ratio was not equal to the presence of monoclonal gammopathy, and observation of a normal ratio does not exclude the presence of monoclonal gammopathy.

The challenging diagnosis of intravascular large B-cell lymphoma

Livedo reticularis (LR) is a net-like cyanotic skin pattern resulting from cutaneous blood flow disturbance associated with several medical conditions. The authors present a case of a 77-year-old woman with a history of asthenia over one year, admitted to the hospital with sepsis by pneumonia. During her hospitalization, she developed a livedoid rash, and skin biopsy revealed infiltrates of atypical mononuclear cells causing capillary lumen obstruction. Intravascular large B-cell lymphoma was suspected and confirmed by bone marrow study. This case highlights the importance of being aware of different medical conditions associated with LR and the atypical presentation of a lymphoproliferative disorder.

Clinico-haematological profile of adult pancytopenia patients at a tertiary care institute in South India

Background: Pancytopenia is not a disease by itself; rather it describes simultaneous presence of anemia, leukopenia and thrombocytopenia resulting from a number of disease processes. Varieties of hematological and non-hematological disorders may affect bone marrow either primarily or secondarily, resulting in the manifestation of pancytopenia. The incidence of various hematological disorders causing pancytopenia varies due to geographical distribution and genetic predisposition. This study highlights the spectrum of causes, clinical presentation and bone marrow morphology of pancytopenia.Methods: This prospective observational study was conducted for a period of two years at Al-Ameen Medical College, Bijapur, Bangalore. During this period, fifty patients with a hematological diagnosis of pancytopenia were studied during period in the department of pathology.Results: Among the 50 cases studied, 35 were males and 15 were females. Most of the patients presented with generalized weakness and fever. The commonest physical finding was pallor, followed by splenomegaly and hepatomegaly. Dimorphic anemia was predominant blood picture. Bone marrow study showed 72% hypercellular marrow, 12% normocellular and 16% hypocellular marrow. The commonest cause for pancytopenia was megaloblastic anemia followed by iron deficiency anaemia and malaria.Conclusions: The present study concludes that detailed hematological investigations along with bone marrow examination in pancytopenic patients is helpful to diagnose or rule out the causes of pancytopenia.

Correlation of Bone Marrow Morphology and Immunophenotyping in Acute Leukaemia Patients

Background: Acute leukaemia (AL) is a malignant disorder of the blood that is characterized by blocked or impaired differentiation of haemopoietic stem cells, resulting in abnormal accumulation of immature precursors and suppression of growth and maturation of cells in vivo. Objective: To find out correlation between morphological and immunophenotypic study of bone marrow among acute leukaemia patient. Methods/Procedure: This is a comparative cross sectional study of diagnosis of leukaemia by bone marrow study and immunophenotyping from bone marrow sample with bone marrow alone of suspected cases of leukaemia treated in the department of haematology in Dhaka Medical College Hospital (DMCH)from March 2013 to August 2013 .Bone marrow examination and immunophenotyping was done simultaneously but having bone marrow morphology report we have compared with flow report. Results: Out of 50 patients according to Bone marrow study (BMS) 25(50.0%) of the patients had acute myelogenous leukaemia, 24(48.0%) had acute lymphoblastic leukaemia and 1(2.0%) had acute leukaemia. On the other hand, in immunophenotyping 28(56.0%) patients had acute lymphoblastic leukaemia, 20(40.0%) had acute myelogenous leukaemia and 2(4.0%) mixed cell immunophenotyping. Discordance of diagnosis was found in 3(6%) is diagnose as AML which was ALL on flow and one acute leukaemia and one AML was subsequently diagnose as mixed cellular leukaemia. Conclusion: Subjective variation in the accuracy of diagnosis of leukaemia on the basis of bone marrow study alone may occur. Inclusion of immunophenotyping with bone marrow study improves accuracy of leukaemia.

Evaluation of haematological findings in cases of pancytopenia

Background: Pancytopenia is a clinical condition which poses diagnostic challenge to the haematologist. The aetiology of pancytopenia is varied and depends on many factors. A bone marrow study is highly indicated in cases of pancytopenia and it provides information regarding the underlying disease process. This study was done to learn the causes of pancytopenia and to document how each case was evaluated and followed up.Methods: The present study is a descriptive retrospective one year study on bone marrow samples received in the laboratory. Bone marrow samples included aspirate smears, imprint and trephine and their findings were correlated to arrive at a final diagnosis.Results: Out of the total 28 patients with pancytopenia, 35.71% were from the age group between 61 and 80 years. A male female ratio of 1.5:1 was observed. Most common presenting complaint documented was easy fatiguability. Anisocytosis with macrocytes and ovalocytes were the most common peripheral smear finding. In current study, a cellular marrow was described in 24 (85.71%) cases and hypocellularity in two (7.14%) cases. Final diagnosis was evident in 16 cases, in which the most common cause was acute leukaemia (14.28% each) followed by lymphoma infiltration and myelodysplastic syndromes in 3 cases (10.71%).Conclusions: Bone marrow study helps to arrive at a diagnosis of pancytopenia. But proper technique for sampling, good clinical workup and history taking and clinico haematological correlation is mandatory for the proper diagnosis of a pancytopenia case.

And the Oscar goes to peripheral blood film for detection of lead poisoning in a complicated patient: A case report with review of laboratory clues

Background Peripheral blood smear examination is an invaluable laboratory test which provides the complete hematologic and/or non-hematologic picture of a case. In addition to verifying the results of automated cell counters, it has the potential to identify some pathologic morphologic changes that remain hidden using the cell counters alone. Case presentation A 40-year-old man with a 3 year history of alcohol intake and marijuana abuse presented with severe lower extremities bone pain and abdominal pain. Physical examination showed high blood pressure, high pulse rate and abdominal tenderness. He underwent extensive laboratory and imaging tests, and cholecystectomy and bone marrow study, without any definite diagnosis or improvement. Right after all these invasive, expensive and time consuming investigations during a month, finding a point on the peripheral blood smear by an expert led to the final diagnosis. The finding was coarse basophilic stippling in the red blood cells. Elevated blood lead level and the presence of ring sideroblast in the bone marrow study confirmed the diagnosis of lead poisoning and the patient responded well to chelator therapy in a short period. Conclusion This case clearly shows the value of peripheral blood smear review and its impact on the patient care. In order not to lose the cases, laboratories are recommended to design their own policy for peripheral blood smear review. Peripheral blood smear is the fastest, simplest, and most available screening test which could prevent many misdiagnoses and malpractices. It provides rich morphological information, among which basophilic stippling is highly suggestive of lead poisoning.

Clinical profile of hypochromic microcytic anemia in Chittoor district, India

Background: Anemia is not a diagnosis by itself like fever but merely is an objective sign of the presence of disease. The correct diagnostic terminology for a child with anemia requires the detection of etiology, pathology, and pathogenesis of the anemia. To evaluate the role of therapeutic oral iron therapy as a diagnostic approach to hypochromic microcytic anemia.Methods: The present study is a retrospective study conducted at the teaching hospital, Chittoor district from September 2019 to December 2019. A total number of 350 cases of anemia were studied from both inpatient and outpatient services in the age group 2 months to 12 years. Hemogram, Hb Electrophoresis, and bone marrow study as necessary based on individual cases.Results: From the above analysis, the mean Hb% at the time of entry to study was 7.36gms%. The mean Hb% after the iron therapy was 11.8gms%. The mean increase in Hb was 4.4gms%. In this study, the average RBC count was 2.9 million cells/cumm.Conclusions: A therapeutic trial of oral iron is an appropriate initial step in the diagnostic approach of hypochromic microcytic anemia. Costly investigations like Hb electrophoresis and bone marrow study are required only in selected cases.

Study of etiological spectrum and clinical profile of patients admitted in tertiary care hospital of South Gujarat, India

Background: Pancytopenia is defined as reduction of all three formed elements of blood below normal reference range. The symptoms are fatigue, fever, dizziness and weight loss. Evaluation was done using complete hemogram and peripheral smear. The presenting marrow biopsy is most useful and accurate in evaluation of pancytopenia.Methods: Two ml of anticoagulated blood was collected for complete hemogram. The peripheral blood smear was stained with Leishman's stain and studied. Bone marrow biopsy and aspiration was done in all the patients to identify etiology.Results: Predominance was seen in the age group of 31-60 years. Most common cause of pancytopenia was megaloblastic anaemia in this study compared to other studies all over the world where most common cause was aplastic anaemia. This reflects higher prevalence of megaloblastic anaemia in the Indian subjects.Conclusions: A comprehensive clinical, haematological land bone marrow study of patients with pancytopenia usually helps in identification of the underlying cause.