Monoclonal Peak Research Articles

Electrophoresis of Proteins in the Biochemistry Laboratory of the University Hospital of Brazzaville

Background and aim: The electrophoresis of serum proteins is one of the examinations requested at the Biochemistry laboratory, with a view to highlight various pathologies. The aim of our study is to analyze the different electrophoretic profiles encountered in our current practice. Methods: This is a retrospective study of 350 serum samples collected at the biochemistry laboratory of the University Hospital Center (CHU) of Brazzaville. The electrophoresis of serum proteins was carried out on a Minicap Flex Piercing machine from Sebia. Results: One hundred and ninety-five (195) sera from women and 155 sera from men were collected from patients aged 12 to 85 years. Ninety-one, or 26% of PSE were normal. Two hundred and fifty nine or 74% were pathological. Inflammation was noted in 194 (55%) of cases of which 145 (41%) were chronic and 49 (14%) acute. Forty-two (12%) of our patients had beta-gamma block and 11 (3%) others presented with nephrotic syndrome. Monoclonal peaks were observed in 12 patients (3%). Conclusion: This study highlights the plurality of different electrophoretic profiles, with a predominance of profiles emanating from the Gastro-Enterology department. It nevertheless reveals the question of relevance in the request for these examinations, since no clinical information is documented for the attention of the clinical practitioner.

Multiple Myeloma Course with Renal Insufficiency in Young Patient: Case Report

Introduction: Multiple myeloma (MM) is a malignant neoplasm characterized by the clonal proliferation of abnormal plasma cells in the bone marrow (OM). The average age of patients diagnosed with MM is approximately 70 years, being relatively uncommon in younger individuals. Objective: To report a case of a young patient with multiple myeloma. Case Description: A 42-year-old male patient presented with continuous and progressive low back pain for 3 months, associated with adynamia, weight loss (10 kg), episodes of constipation and bleeding in the oral cavity in this period. Examinations at the first appointment revealed moderate anemia (Hb 7.4 g / dL), leukocytosis, thrombocytopenia, hypercalcemia, and altered renal function (Cr 5.9 and Ur 178), chest tomography indicating vertebral fracture in T6, T11, L2 and L4. Referred for specialized follow-up, he performed electrophoresis of serum proteins with the presence of a monoclonal peak in the gamma globulin fraction. The immunofixation test confirmed monoclonality for IgA isotype and Kappa light chain (IgA / Kappa). The myelogram showed plasmacytosis of more than 50% of mononuclear cells in the bone marrow. He developed renal failure (with dosage of creatinine of 10.1 mg/ dL. and urea of 208 mg/dL) and hypercalcemia requiring dialysis therapy on the third day of hospitalization, having undergone chemotherapy with Bortezomib, cyclophosphamide and dexamethasone. During this period, infection by the multisensitive S. aureus in catheter occurred and, despite being treated with specific antibiotic therapy, it evolved with clinical worsening and hemodynamic instability and was referred to the Intensive Care Unit, going to death after 2 days. Conclusion: Young patients with MM may study with more aggressive characteristics. Despite the use of new therapeutic agents, more effective treatment strategies need to be studied more for patients in this age group. Disclosures No relevant conflicts of interest to declare.

An Unusual Case Of Pernio (Chilblains) With Underlying Cryoglobulinemia – Case Study

Abstract Introduction/Objective Pernio or chilblains, is a rare condition associated with small pruritic swellings of the extremities triggered by low temperature. Generally, the patients experience a burning and itching sensation in the affected areas that increases with return to warm temperature. The underlying risk factors include autoimmune disorders and cryoglobulinemia. Herein we present an unusual and rare case of chilblains that evaded diagnosis for few years. The general concepts of analytical and clinical evaluations of this condition, with emphasis on accurate diagnosis of gammopathies, along with the importance of laboratory evaluations and accurate interpretation of laboratory results will be discussed. Methods Multiple laboratory investigations (CBC, electrolyte analysis, serum protein electrophoresis, free light chain analysis) were pursued together with skin biopsies. Additionally, CT scan under low radiation exposure and bone marrow biopsy were followed. Plasma sample viscosity at room temperature was evaluated. Results Skin biopsies from right anterior thigh and left arm revealed leucocytoclastic vasculitis with normal perivascular staining for C3 and fibrinogen. Serum sample at room temperature exhibited increased viscosity and protein electrophoresis identified a highly elevated IgG kappa monoclonal globulin peak whose concentration increased upon warming and dilution of the sample, suggesting that agglutinin precipitated at cold temperature (below body temperature). Analysis of free light chains revealed elevated concentration of kappa light chain whose concentration also increased upon warming the serum sample. Whole body CT scan and bone marrow biopsy analysis further identified lytic lesions. These investigations established the diagnosis of plasma cell myeloma (CD138 staining) with expression of monoclonal immunoglobulin precipitating at temperatures below that of the body. Conclusion Given the above findings this case of chilblains can be classified as cryoglobulinemia vasculitis. The importance of attention to details (e.g. characteristics of serum samples), accurate interpretation of laboratory findings and analysis clinical information are all very crucial to arrive at a differential diagnosis.

MM-098: A Case Report: Acquired Pure Red Cell Aplasia Associated with Monoclonal Gammopathy of Undetermined Significance

Background: Pure Red Cell Aplasia (PRCA) is a rare disorder characterized by profound anemia and absence of erythroid precursor in the bone marrow, and it can be genetic or acquired; the acquired form can be idiopathic or secondary and one of these causes is monoclonal gammopathy (MG). In review of the literature, we found a few cases that were treated in different ways. Case Presentation: We will report a case of pure red cell aplasia associated with monoclonal gammopathy of undetermined significance; the patient admitted for severe anemia with hemoglobin 5.4 g/dl, MCV 120 fl, and white blood count (WBC) was 3750/mm3 with 67% neutrophils and a normal platelet count. The workup was done and showed a reticulocyte count of 0.03%, negative coombs (direct and indirect), negative ANA, and anti-double stranded DNA (dsDNA). Vitamin B12 was 900 pg/ml and folate 7.66 ng/ml; serology for HIV, HBV, and HCV found to be negative. TSH, LDH, liver function tests were all normal. Erythropoietin level was 11.79 IU/L. Bone marrow aspirate revealed a cellular bone marrow (60-70%) with less than 5% plasma cells expressing excess lambda light chain. Immunohistochemistry using CD138 confirmed the result and flow cytometry revealed a small population of plasma cells with aberrant phenotype. Serum protein electrophoresis showed a monoclonal gamma peak and immunofixation showed high light lambda chains. Total body MRI showed diffuse infiltrative marrow disorder. Patient was treated with Lenalidomide 25 mg daily on days 1-21 of repeated 28-day cycles and Dexamethaxone 8 mg twice weekly with excellent response. After 6 months of treatment and follow-up, patient had normal bone marrow cytology, normal hemoglobin, and normal reticulocyte count.

P0257CLINICOPATHOLOGICAL SPECTRUM OF KIDNEY INVOLVEMENT IN MONOCLONAL GAMMOPATGY

Abstract Background and Aims The occurrence of kidney diseases associated with a monoclonal gammopathy is increasingly recognized.Renal biopsy and evaluation by light microscopy, electron microscopy and immunofluorescence,in association with adequate clinical examination are essential in accurate diagnosis. The objective of our study is to describe the types of kidney damage secodary to monoclonal gammopathies and to study its renal prognosis. Method It is a monocentric RETOSPECTIVE DESCRIPTIVE STUDY carried out in the nephrology department of CHU FATTOUMA BOURGUIBA MONASTIR spread over a period of 7 years from January 2012 to December 2018. Results we collected 40 cases of monoclonal gammopathies. The median age was 61 years.The sex ratio was 0,9. the circumstances of discovery were dominated by renal failure. it revealed the diagnosis in 77.5% of cases. the renal presentation proteinuria in 70%, microscopic hematuria in 12.5%, edematous syndrome in 27.5% and nephrotic syndrome in 37,5%. The mean creatinine level was 500 umol / L and proteinuria at 4,3 g / 24 h with a maximum rate of 17.5 g / 24h. the electrophoresis of serum proteins showed the presence of a monoclonal peak in 90% of the cases in the gamma zone. The plasmocytosis was less than 10% in 15% of cases and more than 60% in 22,5% of the cases. Radiology showed bone localizations in 32,5% of cases. These gammopathies were classified as Multiple myeloma in34 patients, POEMS in one case and 5 MGRS. Kidney biopsy was performed in 10 patients showing cast nephropathy, AL amyloidosis and vasculites(endocapillary glomerulonephritis with hyaline thrombi in all vessels and double contour appearance of the glomerular basement membrane) in respectively 12,5%, 7,5% and 2,5% of cases. the main indications were rapidly progressive renal failure, unexplained acute renal failure and nephrotic syndrome. The renal involvement retained was a myeloma tubulopathy in 28 patients, 3 of whom were confirmed histologically . AL amyloidosis was found in 5 patients and the confirmation was histological. Type 1 cryoglobulinemia was diagnosed in only one patient. Glomerular nephropathy remained undetermined in 6 patients whose PBR was indicated but not made in the presence of hemostasis disorders. The chemotherapy was started in 34 patients based on bortezomide-thalidomide-dexamethasone in 30% of cases. An autograft of the bone marrow was done in one patient. Hemodialysis was required in 15 patients. The renal function was improved in 42.5% of the cases and a passage on chronic hemodialysis in 10% of cases. 10% of patients have achieved complete hematological remission. Conclusion Patients with MG can develop a large variety of related renal lesions.Renal involvement darkens the prognosis hence the need for adequate care .

Quantification by Ultrafiltration and Immunofixation Electrophoresis Testing for Monoclonal Serum Free Light Chains.

Measurement of monoclonal immunoglobulins is a reliable estimate of the plasma cell tumor mass. About 15% of plasma cell myelomas secrete light chains only. The concentration of serum free light chains is insufficient evidence of the monoclonal light chain burden. A sensitive quantitative estimate of serum free monoclonal light chains could be useful for monitoring patients with light chain myeloma. We describe such an assay that does not require mass-spectrometry equipment or expertise. Serum specimens from patients with known light chain myelomas and controls were subjected to ultrafiltration through a membrane with pore size of 50 kDa. The filtrate was concentrated and tested by immunofixation electrophoresis. The relative area under the monoclonal peak, compared to that of the total involved light chain composition, was estimated by densitometric scanning of immunofixation gels. The proportion of the area occupied by the monoclonal peak in representative densitometric scans was used to arrive at the total serum concentration of the monoclonal serum free light chains. Using an ultracentrifugation and concentration process, monoclonal serum free light chains were detectable, along with polyclonal light chains, in all 10 patients with active light chain myelomas. Monoclonal light chains were identified in serum specimens that did not reveal monoclonal light chains by conventional immunofixation electrophoresis. The limit of detection by this method was 1.0 mg/L of monoclonal serum free light chains. The method described here is simple enough to be implemented in academic medical center clinical laboratories and does not require special reagents, equipment, or expertise. Even though urine examination is the preferred method for the diagnosis of light chain plasma cell myelomas, measurement of the concentration of serum free light chains provides a convenient, albeit inadequate, way to monitor the course of disease. The method described here allows effective electrophoretic differentiation of monoclonal serum free light chain from polyclonal serum free light chains and provides a quantitation of the monoclonal serum free light chains in monitoring light chain monoclonal gammopathies.

Maladies des chaînes lourdes

In most plasma cell disorders, monoclonal proteins have a structure similar to normal molecules but in abnormal amounts. Heavy chain disease (HCD) is a rare pathology defined by the presence of a monoclonal immunoglobulin (Ig) of abnormal structure, consisting only of an incomplete fragment of the heavy chain (truncated) and devoid of light chains, remarkable for the frequency of associated immunological or haematological diseases.Abnormal lymphocytes or plasma cells secrete the different types of heavy chains (alpha [α], gamma [γ], mu [μ] or delta [δ]) without light chains. The majority of heavy chain proteins are fragments of their normal counterparts with internal deletions of variable length. These deletions seem to result from structural mutations.There are 4 types of MCL according to the Ig heavy chain class produced by clonal cells: α, γ, μ or δ. The clinical presentation is closer to that of lymphoma than to multiple myeloma.The diagnosis of HCD and related diseases is based on the histological study of affected tissues and the analysis of serum or urine. The histological analysis with immunostaining shows a positive monoclonal population for a heavy chain, but negative for the two kappa (κ) and lambda (λ) light chains.The frequency of detection of the monoclonal peak is variable and depends on the type of HCD. The prognosis of these diseases is very variable from one patient to another and the treatment is not standardized.

SUN-390 MIXED AMYLOSE AA AND AL

Systemic amyloidosis is a rare disease that can affect multiple organs. Renal involvement is the most common and the most clinically expressive. Its diagnosis is histological based on the presence of amyloid deposits which are most often either type AA essentially complicating infections and chronic inflammatory rheumatism, either of primitive AL type or during dysglobulinemia. This presentaion is about the first case in ou the first case of mixed amyloidosi AL and AA. Descriptive presentation of the first mixed amylosis AA and AL that occured in the nephrology departement of Sahloul hospital in 2019. The case of a 66-year-old man with a history of treated and cured tuberculosis, gout and benign prostatic hypertrophy who was admitted to primary renal insufficiency with a creatinine count of 1078 was presented. Examination the patient had a small tension and clinical splenomegaly. In biology were found bi cytopenia with normochromic normocytic anemia, leukopenia and nephrotic syndrome. Plasma protein electrophoresis was performed and showed hypogammaglobulinemia at 4.9 with a monoclonal peak estimated at 2.1 g / l of gamma globulins, complement by imminotyping was in favor of an IgG Lamda type monoclonal peak. Sternal puncture was performed and the diagnosis of myeloma was eliminated with a plasma cell count estimated at 6% and negative CRAB criteria. To confirm the diagnosis of amyloidosis, in front of the appearance of small kidneys, the only recourse was to perform a biopsy of accessory salivary glands which had confirmed the diagnosis of amyloidosis with histochemistry SAA (+) Kappa (-) Lamda (+). Series of complementary tests whose tumor markers were measured and showed only an increased ACE level. However, upper digestive fibroscopy and colonoscopy were normal. The patient was treated with dialysis at a rate of two sessions per week. The course was marked by a general condition preserved with onset during hospitalization of a periorbital bruise. In view of the imminilogical clinical arguments and the etiological investigation the diagnosis retained was mixed amyloidosis as a new entity and the end stage renal failure patient was adressed to hematology to manage his gammopathy. AA amyloidosis is deposited during tuberculosis, a major cause in developing countries. In our case and after eliminating a secondary cause, that was the probable cause of this AA amyloidosis. However, the clinical and biological examination did not show any activity of this tuberculosis. The patient had also a monoclonal peak of IgG lamda type with a 6% plasma cells level at the sternal puncture. This suggests the presence of a monoclonal gammopathy at the origin of AL amyloidosis especially with the appearance on clinical examination of peri-orbital eccymosis. The diagnosis of the probability of AL amyloidosis is sometimes focused on a set of arguments: clinical context compatible with AL amyloidosis, presence of serum / urinary monoclonal gammopathy or a clonal medullary plasma cell population with light chain assay. We suggest, after all these arguments the presence in this patient the first case of a mixed amyloidosis AA and AL. The techniques for identifying the nature of amyloid deposits by proteomics, currently under development, should allow in the future to identify precisely the type of amyloidosis in the majority of cases.

SAT-383 Which characteristics of Multiple Myeloma in the internal medicine and nephrology department?

Multiple myeloma is a malignant plasma cell dyscrasia, linked to a monoclonal immunoglobulin secretion. The aim of this work was to describe the feature of diagnosis, therapy and outcome of hospitalized patients and followed in nephrology. We realized a descriptive retrospective study carried out in the department of internal medicine and nephrology of the Military Hospital of Tunis from January 2015 to October 2019. We included in this study patients followed for Multiple Myeloma diagnosed on the basis of the International Myeloma group criteria. There were 12 men (60%) and 8 women (40%) with a median age 65 years old. The inaugural symptoms were dominated by renal failure, general signs, and bone pain in respectively 90%, 70% and 55% of cases. Otherwise, 85% of the patients had anemia with an average range of hemoglobin 8.78 g/dl associated to a thrombocytopenia and bicytopenia in respectively 4 and 2 cases. Hypercalcemia was founded in 60% of cases with a median calcemia 2.6 mmol/l. The median creatinine at diagnosis was 370 μmol/l. The median proteinuria was 4.93 g/24h. Hyperproteinemia was founded in 4 cases, a monoclonal peak in 7 cases and hypogammaglobinemia in 5 cases. The average percentage of bone morrow plasma cell infiltration was 45 %. Radiological assessment was realized in all patients and it founded evocative bone lesions of MM in 70% of cases. The study of prognostic factors showed a high average of beta 2 microglobulin in 63 % of cases, hypoalbuminemia in 70% of cases, elevated CRP in 4 cases and a high average of LDH in one case. The research of cytogenetic abnormalities with FISH was done in 63% of cases, showed a deletion (17q) in one patient and translocation (4,14) in 2 patients. Concerning therapeuticmodalities, all patients have received hydration. Four patients have needed hemodialysis sessions. The bisphosphonates were prescribed in 40% of cases. For patients under 65-year-old, the protocol VTD (Velcade-Thalidomide-Dexamethasone) was prescribed in 9 cases and the ALEXANIAN modified (Dexamethasone-Thalidomide-Cyclophosphamide) in 2 cases. In the over side, for patients older than 65 years, the protocol MD (Melphalan-Dexamethasone), VTD and Dexamethasone-Thalidomide were prescribed respectively in 4, 1 and 2 patients. A therapeutic abstention was been indicated for one patient. The hematological evolution was marked by a complete remission in 7 cases (2 patients have benefited of autologous hematopoietic stem cell), incomplete remission in 6 cases, and absence of remission in 3 cases. About the renal outcome, 7 patients had a chronic renal failure and 3 patients had end-stage chronic renal disease and 6 patients were dead. In our study, the MM had the feature to occur in a much younger age with a male predominance. The renal failure was the most frequent compared to other series and this is explained by the selection bias. The MM is a malignant hematology disease with easy diagnosis criteria but it is frequently lately diagnosed. A collegial patient care management is required to improve the prognosis of this pathology.

Association of Multiple Myeloma and Giant Cell Arteritis - A Case Report.

Autoimmune diseases (AID) have been associated with a variety of lymphoproliferative disorders. Multiple myeloma (MM), one of the most common haematologic malignancies characterized by clonal proliferation of bone marrow plasma cells, has been associated with a range of autoimmune disorders. In this report, we described a case study of a patient admitted to our Internal Medicine Department for a bone marrow biopsy and myelogram due to a monoclonal peak observed by his general practitioner. However, at admission he presented typical giant cell arteritis (GCA) complaints, suggesting the coexistence of both diseases. The possible pathogenesis, as found in the literature, explaining the association will be discussed.LEARNING POINTSA relationship between AID and lymphoproliferative diseases, although rare, may occur and some studies suggest that the diagnosis of autoimmune disease has a negative impact on survival in MM patients.Bone marrow plasmacytosis can present a diagnostic dilemma, since it may be due to neoplastic or non-neoplastic conditions (that is, reactive plasmacytosis associated with AID, chronic infection, metastatic carcinoma, liver diseases and acquired immunodeficiency).Immunophenotyping in a myelogram or immunohistochemistry in bone marrow studies are useful in confirming a monoclonal plasma cell proliferation.

Comparison of the Performance of Surface Alone or Surface Plus Cytoplasmic Approaches for the Assessment of Minimal Residual Disease in Multiparameter Flow Cytometry in Multiple Myeloma

Background. During the follow-up of treated myeloma patients, the assessment of minimal residual disease (MRD) is gaining an increasing importance. The detection of remaining abnormal plasma-cells (PC) may rely on molecular techniques investigating immunoglobulin rearrangements of the malignant clone or on multiparameter flow cytometry (MFC). The latter allows to obtain a rapid response by dealing with fresh cells. It also focuses on cells still alive, since dead cells are discarded as debris. Numerous publications have reported that the most reliable markers of PC in MFC are CD38 and CD138 their co-expression being a good way to select the population of PC in a bone marrow (BM) or, more rarely tested, blood sample. Malignant PC often but not always differ from normal PC by the loss of CD19 expression and the acquisition of CD56. Other immunophenotypic alterations are related, among others, to the expression of CD20, CD27, CD28, CD33, CD45, CD81 or CD117. Malignant PC also display the monotypic usage of light chains by the myelomatous immunoglobulin, which can readily be assessed in MFC after permeabilization of the PC, although this induces an additional technical step that could induce some cell loss. Here we compared the two panels proposed by the Euroflow consortium (Flores Montero, 2018) which use the same backbone of antibodies with a "surface" strategy associating CD81 and CD117 or a "cytoplasmic" strategy investigating for the expression of kappa and lambda immunoglobulin light chains. Methods. From a cohort of patients for whom MRD had been assessed in our MFC platform, 100 samples were retrospectively selected as displaying detectable MRD in the cytoplasmic strategy. All BM samples had first been submitted to bulk lysis to increase the PC concentration. Between 5 and 10x106 nucleated cells were used for surface staining, premeabilization and intracytoplasmic staining. Another aliquot of the same suspension, with 3 to 5x106 nucleated cells, was used for the "surface" tube. Briefly, both samples were surface stained with antibodies to CD45 (Ozyme), CD19 (Beckman Coulter), CD38 (Cytognos), CD138 (BD Biosciences) and CD27 (Ozyme). The "surface tube" also contained antibodies to CD81 (Clinisciences) and CD117 (BD Biosciences). After this incubation, the "cytoplasmic tube" was submitted to permeabilization (Intrastain® Dako) and cells further incubated with antibodies to kappa and lambda chains (Dako and Clinisciences). All samples were acquired on the same day. Listmodes of the "cytoplasmic tubes" were analyzed and data provided to the clinician within 24 hours. For this study, the listmodes of the "surface tube" were analyzed blindly using the Kaluza® software. Data were then compared to those of the "cytoplasmic tube" Results. A good linear correlation was observed between the two results, with a R2 coefficient of 0.73. The global difference between both tubes was usually a lower MRD level detected with the "cytoplasmic tube", seen in 68% of the cases (median -0.0113; range -0.0001 to -1.4). Of note higher levels (0.0007 to 1.44) were observed in 32%, ruling out a systematic loss of cells that could have been responsible for this difference. The gating strategy adopted (Robillard 2013) delineated four populations on a CD19/CD56 bivariate histogram. Monotypy was then investigated in each of the four subsets thus identified. The same strategy was applied for the "surface tube" looking at the coexpression profile of CD81 and CD117 in each subset. Globally, 58% of the samples were CD56 positive among which 43 were CD19-. CD19 was also absent in 40 CD56- samples. All configurations of CD117 and CD81 coexpression were seen, making each patient a challenging case. In about 10% of the cases, two suspect subsets were seen in the "surface tube" while monotypy was seen in only one in the "cytoplasmic tube". Conclusion. Although this study shows a good correlation between the two panels, it was found that a greater confidence could be attributed to the "cytoplasmic tube", where data are comforted by identification of a monotypic population with the same light chain as the monoclonal peak. Moreover, although confirmation of the abnormal subset was required in numerous cases with the "surface tube", the reverse was never observed. Single use of the "cytoplasmic" combination can thus be recommended as a robust method of MRD assessment in multiple myeloma. Disclosures Moreau: AbbVie: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Janssen: Consultancy, Honoraria; Takeda: Consultancy, Honoraria; Celgene: Consultancy, Honoraria.

Mieloma múltiple asociado con hiperbetaglobulinemia en paciente cirrótico. Reporte de caso

Introducción: el mieloma múltiple es una enfermedad hematooncológica de origen clonal, caracterizada por la producción anormal de células plasmáticas que producen un reemplazo progresivo de otras líneas hematopoyéticas. El 95 % de los casos condiciona el aumento de la producción de inmunoglobulinas defectuosas, predominantemente IgG e IgA, detectadas en suero con pico monoclonal, definido por un deterioro progresivo de la función renal aguda, anemia, citopenias, dolor óseo agudo o crónico, fracturas patológicas, trastornos endocrinos recientes y, como en el caso de estudio, asociado con cirrosis hepática. Presentación del caso: paciente masculino de 49 años, con cefalea, dolor abdominal, torácico, evacuaciones melénicas, disnea y signos de ascitis, con un tiempo de enfermedad de tres meses, con historia de dolor lumbosacro de tres años antes de su ingreso. Los exámenes auxiliares mostraron pancitopenia, perfil de coagulación alterado, función renal alterada, inversión de albúmina-globulina, hiperuricemia, ascitis, lesiones óseas líticas, hipergammapatía monoclonal de tipo IgA relacionado con hiperbetaglobulinemia. Los exámenes específicos dieron como diagnóstico mieloma múltiple IgA EC IIIB más cirrosis hepática. Se presenta este caso como inusual por elevación de proteínas en suero, tanto beta como gamma, producto de dos patologías concomitantes. Conclusión: paciente con dos enfermedades simultáneas, en ambos casos con elevación de globulinas, lo que podría confundir el diagnóstico; el estado de inmunosupresión mejora con la administración de inmunoglobulinas y de tratamiento para la enfermedad base.

2757 Gastric Amyloid: The Patient Who Could Not Eat at AL

INTRODUCTION: Gastroparesis is defined as delayed gastric emptying in the absence of mechanical obstruction. Diabetes and medication side effects are common causes. AL amyloidosis is a systemic disease due to extracellular fibril deposition that can affect multiple organs. Gastro-intestinal (GI) involvement is less common than in other organ systems but can present in many different ways, including gastroparesis. CASE DESCRIPTION/METHODS: A 77 year old non-diabetic man from Mississippi presented with a one year history of intermittent abdominal distention, nausea and bloating. In addition, he had increasing dyspnea on exertion and lower extremity edema. Outside work-up consisted of multiple imaging studies demonstrating marked gastric distention as well as delayed gastric emptying (Figures 1 and 2). Outside colonoscopy was unrevealing and EGD was negative except for a distal esophageal ulcer and focal active duodenitis. He was started on a PPI and trialed on an alternating regimen of metoclopramide and erythromycin, without symptomatic relief. He was referred to our hospital for further diagnostic work-up. Repeat colonoscopy showed congested distal ileal mucosa and friable ascending colonic mucosa. Biopsies from both sites revealed amyloid deposits by Congo red stain (Figure 3). Serum protein electrophoresis noted a monoclonal IgG lambda peak with M-spike of 1.5 g/dL and bone marrow biopsy revealed approximately 70% of marrow cellularity consisting of plasma cells. Echocardiogram confirmed severely increased concentric left ventricular wall thickening consistent with cardiac amyloidosis. Interestingly, neither fat pad biopsy nor bone marrow biopsy showed presence of amyloid. The patient was diagnosed with myeloma and AL amyloidosis with gastro-intestinal and cardiac involvement. DISCUSSION: This case highlights the broad differential for gastric distention and dysmotility. When the ‘usual suspects’ such as diabetes, medication, post-surgery and neurological disease have been ruled out, rarer causes like an infiltrative process should be considered. Common manifestations of GI tract amyloidosis include GI bleeding, malabsorption, protein-losing enteropathy and chronic dysmotility. The diagnosis of amyloidosis is based on positive tissue diagnosis. While the combination of a fat pad and a bone marrow biopsy has a high sensitivity (89%) for diagnosing AL amyloidosis, negative results do not rule out amyloid elsewhere and tissue sampling from the affected organ site is essential, as demonstrated in this case.

Paraproteins. A review

Hematological neoplasms are tumors of cells in different states of maturation and differentiation. Since monoclonal gammopathies (MG) refer to B mature lymphocyte neoplasms, lymphogenesis should be well known. We must keep in mind that the last stage of maturation of these lymphocytes is the plasma cell. This is how a MG could appear in the context of a plasma cell neoplasm, such as multiple myeloma or amyloidosis, but also in relation to a lymphoma. A monoclonal peak is produced by mature B lymphocytes or plasma cells that secrete a monoclonal protein (Immunoglobulin), and represents a MG. But it must be emphasized that, in the correct clinical context, a hypogammaglobulinemia can represent a MG as well. Another important point is the understanding and interpretation of requested tests, such as protein electrophoresis (PEP), immunofixation (IFx) or serum free light chains (sFLC). The current MG screening panel includes these three studies (PEF, IFx, sFLC), although a simpler panel measuring PEF and sFLC has also been proposed, but not yet formally validated. Therefore, screening done only with PEP is insufficient.

PB1826 COMPOSITE LYMPHOMA CONTAINING MANTLE CELL AND PERIPHERAL T‐CELL LYMPHOMA, NOT OTHERWISE SPECIFIED: A REPORT OF 2 CASES TREATED WITH UP‐FRONT AUTOLOGOUS STEM CELL TRANSPLANTATION.

Background:Composite lymphomas are a rare entity defined by the presence of two different lymphomas in the same patient and in the same organ.Aims:To describe two cases of composite lymphoma comprising mantle‐cell lymphoma (MCL) and peripheral T‐cell lymphoma, not otherwise specified (PTCL, NOS), a very rare association which has only been reported twice in the literature.Methods:Retrospective review of two clinical cases.Results:Case 1: A 64‐year‐old woman presented with B symptoms, massive splenomegaly and systemic lymphadenopathy. Immunohistochemical studies of a lymph node biopsy suggested the presence of two lymphomas, a predominant component of a PTCL, NOS and an in situ mantle cell neoplasia. Fluorescence in situ hybridization (FISH) performed on the paraffin embedded tissue sections confirmed the presence of t(11;14), and a TCRα rearrangement. A monoclonal peak was detected in the IGH PCR analysis. PCR for TCRγ chain also showed a monoclonal peak. The bone marrow biopsy showed a scant infiltration of T‐cells compatible with that seen in the lymph node, with the same TCR rearrangement, suggesting PTCL, NOS infiltration. The patient received six cycles of Rituximab‐CHOP achieving a complete response, and was consolidated with an ASCT. She remained in complete remission for five years, when she relapsed with pancytopenia. Bone marrow biopsy in this moment showed a nodular and interstitial infiltration by small lymphocytes consisting of 40% of total cellularity. Identical IGH gene rearrangement to the one present at the moment of diagnosis, in addition to t(11;14) (FISH) were detected, suggesting a late relapse of the MCL component. Relapse was limited to the bone marrow and the patient started treatment with Ibrutinib achieving a partial response. Recently, Ibrutinib has been discontinued due to different grade 3 infectious complications and the patient remains in partial response without active treatment. Case 2: A 45‐year‐old man presented with an enlarged right tonsil. There were no palpable lymph nodes or B symptoms associated. Image studies confirmed right tonsillar hyperplasia without other findings, and an excisional biopsy was performed to clarify the diagnosis. Contrary to case 1, the biopsy suggested a predominant infiltration of a classical MCL, and an atypical proliferation of T‐cells. Both PCR of IGH and TCR‐γ genes showed the presence of clonal populations. FISH showed CCND1/IGH and TCRα rearrangements. Bone marrow involvement by MCL was confirmed by biopsy. A diagnosis of composite lymphoma (PTCL, NOS and MCL) was stablished. The patient received 3 cycles of Rituximab‐Hyper‐CVAD regimen achieving complete remission. An ASCT was performed to consolidate the response without significant complications. Four years later, he remains free of disease with no later side effects.Summary/Conclusion:The diagnosis of composite lymphomas is challenging and requires a multidisciplinary approach including cytological, immunohistoquemical, cytogenetic and molecular techniques. Treatment aimed to target the most aggressive component of the composite lymphoma is mandatory to achieve a successful result.

PB2114 NEUTROPHILIC LEUKEMOID REACTION ASSOCIATED WITH SMOLDERING MULTIPLE MYELOMA

Background:Chronic neutrophilic leukemia is a rare chronic myeloproliferative neoplasm characterized by splenomegaly, sustained neutrophilia, elevated B12 levels, and negative BCR/ABL translocation. It can be confused with leukemoid reactions in the context of plasma cell neoplasms.Aims:To describe the clinical case of a female patient with neutrophilic leukemoid reaction in the context of latent IgA multiple myeloma treated at the National Cancer Institute of Colombia.MethodsClinical case reportResults:We present a 67‐year‐old woman with a history of type 2 diabetes mellitus and rosacea with headache, epistaxis, fatigue, intermittent chest pain, hyperleukocytosis in the hemograma and qualitative negative PCR BCR ABL in peripheral blood. She received treatment with hydroxyurea since January 2016 extra institutionally. Upon admission to our institution a complete bone marrow study was requested confirming the BCR ABL negativity by cytogenetics and JAK2 V617F negative mutational state, however the myelogram showed infiltration by plasma cell disorder with dohle bodies and moderate megaloblastic changes in the myeloid and erythroid series. Bone marrow biopsy was hypercellular with 30% infiltration by abnormal plasma cells. The immunophenotype of the plasmacytic population in flow cytometry revealed a positive population for CD38/CD138/CD56/B2‐m and negative CD19/CD45 with lambda restriction. Protein electrophoresis showed a monoclonal peak in the beta region, immunofixation was positive for lambda IgA, high IgA levels with a value of 3874 mg/dL. No monoclonal component was detected in the urine, including immunofixation. The free light chains in serum showed a monoclonal lambda of 116.52 mg/L, Kappa 11.01 mg/L with a ratio of 10.5. No CRAB component was shown including PET CT without bone or extramedullary lesions. Despite treatment with hydroxyurea, hyperleukocytosis persisted with 47330 cels/ul with neutrophilia (44060/uL). Finally, smoldering IgA lambda high risk multiple myeloma diagnosis was made. She started treatment with lenalidomide and dexamethasone attaining partial response after two cycles and progresive resolution of leukemoid reaction.Summary/Conclusion:The neutrophilic leukemoid reaction or a similar clinical picture should alert to the existence of a plasma cell neoplasm. The associated morphological characteristics are usually the toxic granulations and Dohle bodies like in our patient. It is not clear if neutrophilia becomes a factor of poor prognosis in smoldering multiple myeloma, for this reason the risk should be stratified according to existing guidelines. There are still controversies about the need for treatment even in higk risk patients. The fact of being IgA, having a peak greater than 3 grams in SPEP, the ratio of light chains greater than 8 were the high‐risk characteristics seen in our patient that they defined in management.image

Interference of daratumumab in the measurement of the monoclonal peak in patients with multiple myeloma

Interference of daratumumab in the measurement of the monoclonal peak in patients with multiple myeloma

Biclonal splenic marginal zone lymphoma with T cell-rich background and aggressive transformation to large cell lymphoma

Marginal zone B cell lymphomas (MZL) are biologically heterogeneous, rarely demonstrating biclonality, complex cytogenetic abnormalities, or T cell predominance. We report a case of biclonal splenic MZL, T cell-rich variant with an abnormal karyotype that progressed to large B cell lymphoma. A 74-year-old female presented with pancytopenia, weight loss, fever, and splenomegaly. Microscopically, the spleen revealed an extensive, vaguely nodular lymphoid proliferation, composed of small lymphocytes, majority of which were reactive T cells. B cells were mostly small and < 5% of total lymphocytes. Focal follicular dendritic cell networks were present, but germinal centers were absent. Flow cytometric analysis revealed two distinct CD5 and CD10 negative B cell clones, one kappa positive and one lambda positive. Conventional cytogenetic analysis revealed the following abnormal karyotype: 47,XX,add(7)(q36),del(7)(q22),add(21)(p11.2),+mar[10]/46,XX[10]. Immunoglobulin heavy chain gene rearrangement showed two monoclonal peaks of different magnitude, consistent with biclonality. Overall, these features favored a low-grade splenic MZL. The staging bone marrow biopsy was normocellular with few interstitial lymphoid aggregates, composed of small lymphocytes, consistent with minimal involvement by low-grade B cell lymphoma. The patient improved without adjuvant chemotherapy; however, 12 months later, she developed anemia and lymphocytosis. Subsequent bone marrow biopsy showed extensive involvement by a large B cell lymphoma and complex karyotype with the previously identified abnormalities, as well as additional numerical and structural aberrations, consistent with cytogenetic evolution and biclonal gene rearrangement. These findings were consistent with transformation. This case demonstrates a unique pathological presentation of splenic MZL with disease progression, highlighting the importance of an integrated approach for lymphoma classification and the difficulties in diagnosing such cases.

MALDI-TOF mass spectrometry distinguishes daratumumab from M-proteins

BackgroundDaratumumab, a therapeutic IgG kappa monoclonal antibody, can cause a false positive interference on electrophoretic assays that are routinely used to monitor patients with monoclonal gammopathies. In this study, we evaluate the ability of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) to distinguish daratumumab from disease-related IgG kappa monoclonal proteins (M-protein). MethodsWaste clinical samples from 31 patients who were receiving daratumumab and had a history of IgG kappa monoclonal gammopathy were collected. Immunoglobulins were purified from serum and analyzed by MALDI-TOF MS. Mass spectra were assessed for the presence of distinct monoclonal proteins. For samples in which only one monoclonal peak was identified near the expected m/z of daratumumab, the Hydrashift 2/4 Daratumumab Assay was used to confirm the presence of an M-protein. ResultsUsing MALDI-TOF MS, daratumumab could be distinguished from M-proteins in 26 out of 31 samples (84%). Results from 2 samples were inconclusive since the M-protein was not detected by the Hydrashift assay and may also be undetectable by MALDI-TOF MS. Comparatively, daratumumab was distinguishable from M-proteins in 14 out of 31 samples (45%) by immunofixation. ConclusionsMALDI-TOF MS offers greater specificity compared to immunofixation for distinguishing daratumumab from M-proteins.

Long Term Survival Analysis of Multiple Myeloma Patients Receiving Induction Therapy+ Autologous STEM CELL Trasplantation, Comparing Velcade-Dexametasone to Alkylating Polichemotherapy As Induction Therapy

Introduction: Multiple Myeloma (MM) is an incurable disease. In young patients, autologous bone marrow transplantation (ABMT) remains a cornerstone treatment after induction therapy. Induction therapy has varied during time, from alkylating polychemotherapy (VBAD,VCMP) or VAD chemotherapy (AVAD) to Velcade-Dexametasone based regimens (VD). We present results of follow-up of a large cohort of patients treated with ABMT. We described overall survival (OS; from transplant to death by any cause) and progression free survival (PFS; from transplant to death by any case or progressive disease defined by reappearance by inmunofixation, or duplication of monoclonal peak after ABMT) , and the impact of induction therapy regiments.Patients: 183 patients transplanted from 2002 to 2017. The median age of the patients was 59 years (33-72). Before 2008 all the patients were treated in alkylating based chemotherapy (42 patients). After 2008 patients were treated with VD based regimens (141patients). Only 12 patients received maintenance therapy based in PETHEMA trials 2005 and 2012. No one patient received a planed second transplant; only 32 patients received a second transplant after relapse as consolidation therapy.Results: Median follow-up of patients still alive is 3.65 years (0.15-14.77). Median OS of all patients was 9.12 years (95% confidence interval (CI): 6.28-NR); Median PFS was 3.02 years(95% CI: 2.46-3.76). At 13 years only 2% of patients remains progression free (CI: 0.00-17%). There were significant differences between patients treated before and after VD regimens. The median OS of patients treated with APVAD was significantly shorter compared to VD (6.22 years, CI[3.39-12] vs. NR, CI[6.28-NR], p=0.025) (HR=0.49, p=0.01).Conclusions: VD schemes of induction before ABMT have improved remarkably OS inpatients with Myeloma; nonetheless, plateau is not observed in EFS. Further analysis must address if EFS could represent a strong indicator of OS, mainly due to novel effective salvage therapies after relapse/refractoriness could be a confounding factor. DisclosuresNo relevant conflicts of interest to declare.