1. CONCEPT MAP CONCEPT MAP

2. 42 y/o male, CC: EDEMA ON BILATERAL EXTREMITIES. Diagnosed with a benign cystic lesion 8 yrs ago S/Sx: BONE PAINS, EASY FATIGUABILITY. OCCASIONAL DIZZINESS, POLYURIA, FREQUENT COUGH + COLDS CBC URINALYSIS

3. 42 y/o male, CC: EDEMA ON BILATERAL EXTREMITIES. Diagnosed with a benign cystic lesion 8 yrs ago S/Sx: BONE PAINS, EASY FATIGUABILITY. OCCASIONAL DIZZINESS, POLYURIA, FREQUENT COUGH + COLDS CBC FINDINGS: - Microcystic. Hypochromic anemia - Neutropenia - Lymphocytosis & plasmacytosis FINDINGS: - Microcystic. Hypochromic anemia - Neutropenia - Lymphocytosis & plasmacytosis URINALYSIS SKULL RADIOGRAPH FINDING: - Multiple raiolucent defects (punched-out lesions) FINDING: - Multiple raiolucent defects (punched-out lesions) ELECTROPHRESIS INDICATION FOR ELECTROPHORESIS: - findings of lytic bone lesions - protenuria, renal insufficiency w/ serum protein elevation - suspicion of multiple myeloma (O’connell et. al. 2005) NORMAL CASE

4. NORMALNORMAL PATIENT SERUM

5. 42 y/o male, CC: EDEMA ON BILATERAL EXTREMITIES. Diagnosed with a benign cystic lesion 8 yrs ago S/Sx: BONE PAINS, EASY FATIGUABILITY. OCCASIONAL DIZZINESS, POLYURIA, FREQUENT COUGH + COLDS CBC FINDINGS: - Microcystic. Hypochromic anemia - Neutropenia - Lymphocytosis & plasmacytosis FINDINGS: - Microcystic. Hypochromic anemia - Neutropenia - Lymphocytosis & plasmacytosis URINALYSIS SKULL RADIOGRAPH FINDING: - Multiple raiolucent defects (punched-out lesions) FINDING: - Multiple raiolucent defects (punched-out lesions) ELECTROPHRESIS Monoclonal M Spikes INDICATION FOR ELECTROPHORESIS: - findings of lytic bone lesions - protenuria, renal insufficiency w/ serum protein elevation - suspicion of multiple myeloma (O’connell et. al. 2005)

6. Monoclonal M Spikes CONSIDER MGUS -USUALLY ASYMPTOMATIC - (-) HYPERCALCEMIA, ANEMIA, RENAL IMPAIRMENT - INCREASE IN M PROTEIN NOT ENOUGH TO CAUSE CHARACTERISTIC “SPIKE” -USUALLY ASYMPTOMATIC - (-) HYPERCALCEMIA, ANEMIA, RENAL IMPAIRMENT - INCREASE IN M PROTEIN NOT ENOUGH TO CAUSE CHARACTERISTIC “SPIKE” URINE PROTEIN ELECTROPHORESIS IMMUNOFIXATION ELECTROPHORESIS

7. URINE PROTEIN ELECTROPHORESIS

8. Monoclonal M Spikes URINE PROTEIN ELECTROPHORESIS IMMUNOFIXATION ELECTROPHORESIS

9. NORMAL PATIENT SERUM

10. Monoclonal M Spikes URINE PROTEIN ELECTROPHORESIS IMMUNOFIXATION ELECTROPHORESIS FINDINGS: 1.PEAK IN GAMMA REGION W/ ALBUMINURIA FINDINGS: 1.PEAK IN GAMMA REGION W/ ALBUMINURIA FINDINGS: 1.SHARP BAND IN THE ANTISERA FOR IgG HEAVY CHAIN 2.SHARP BAND IN KAPPA LIGHT CHAIN FINDINGS: 1.SHARP BAND IN THE ANTISERA FOR IgG HEAVY CHAIN 2.SHARP BAND IN KAPPA LIGHT CHAIN WALDENSTROM MACROGAMMA- GLOBINEMIA WALDENSTROM MULTIPLE MYELOMA

11. WALDENSTROM MACROGAMMA- GLOBINEMIA WALDENSTROM MULTIPLE MYELOMA MULTIPLE MYELOMA BIOPSY FINDINGS: 1.Casts are pink to blue amorphous masses filling the tubular lumen 2.Occasional multinucleated cells surrounding casts IN CONGO RED STAIN: 1.Light chain amyloid deposits (20% are Kappa chain [Korbert & Schwartz, 2006]) 2.Glomerular capillary endothelium have white perpendicular deposits FINDINGS: 1.Casts are pink to blue amorphous masses filling the tubular lumen 2.Occasional multinucleated cells surrounding casts IN CONGO RED STAIN: 1.Light chain amyloid deposits (20% are Kappa chain [Korbert & Schwartz, 2006]) 2.Glomerular capillary endothelium have white perpendicular deposits FINDINGS: 1.Increased number of plasma cells 2.Large plasma cells with basophilic cytoplasm and irregular nuclei 3.There are some multinucleated plasma cells 4.Some with irregularly shaped nuclei with clumped chromatin or some prominent nucleoli FINDINGS: 1.Increased number of plasma cells 2.Large plasma cells with basophilic cytoplasm and irregular nuclei 3.There are some multinucleated plasma cells 4.Some with irregularly shaped nuclei with clumped chromatin or some prominent nucleoli RENAL HISTOPATH BONE MARROW SMEAR

12. WALDENSTROM MACROGAMMA- GLOBINEMIA WALDENSTROM

13. NORMAL GLOMERULUS PATIENTPATIENT

14. NORMAL TUBULES PATIENTPATIENT

15. NORMAL BONE MARROW SMEAR PATIENTPATIENT

16. WALDENSTROM MACROGAMMA- GLOBINEMIA WALDENSTROM MULTIPLE MYELOMA MULTIPLE MYELOMA BIOPSY FINDINGS: 1.Casts are pink to blue amorphous masses filling the tubular lumen 2.Occasional multinucleated cells surrounding casts IN CONGO RED STAIN: 1.Light chain amyloid deposits (20% are Kappa chain [Korbert & Schwartz, 2006]) 2.Glomerular capillary endothelium have white perpendicular deposits FINDINGS: 1.Casts are pink to blue amorphous masses filling the tubular lumen 2.Occasional multinucleated cells surrounding casts IN CONGO RED STAIN: 1.Light chain amyloid deposits (20% are Kappa chain [Korbert & Schwartz, 2006]) 2.Glomerular capillary endothelium have white perpendicular deposits FINDINGS: 1.Increased number of plasma cells 2.Large plasma cells with basophilic cytoplasm and irregular nuclei 3.There are some multinucleated plasma cells 4.Some with irregularly shaped nuclei with clumped chromatin or some prominent nucleoli FINDINGS: 1.Increased number of plasma cells 2.Large plasma cells with basophilic cytoplasm and irregular nuclei 3.There are some multinucleated plasma cells 4.Some with irregularly shaped nuclei with clumped chromatin or some prominent nucleoli RENAL HISTOPATH BONE MARROW SMEAR

17. Final Diagnosis: MULTIPLE MYELOMA WITH PRIMARY RENAL AMYLOIDOSIS Final Diagnosis: MULTIPLE MYELOMA WITH PRIMARY RENAL AMYLOIDOSIS