Table 1: Diagnostic tests.

 

At Diagnosis (with local laboratory references)

Complete Blood Count

Hemoglobin 8.6 g/dL (12-16), Leukocytes 13 103/μL (4-11), Platelets 407 103/μL (150-400).

Renal Function and Electrolytes

Creatinine 0.8 mg/dL (0.6-1.1); Urea 50 mg/dL (21-43); Na+ 126 mEq/L (136-145); K+ 4.4 mEq/L (3.4-5.1); PO43- 3.4 mg/dL (2.3-4.7), Mg2+ 1.65 mg/dL (1.6-2.6), ionized Ca2+ 1.16 mmol/L (1.15-1.35).

Muscle and Cardiac Markers

Troponin 0.031 ng/mL (< 0.032); Myoglobin 165.1 ng/mL (< 146.9); CK 18 U/L (29-168); BNP 1833.7 pg/mL (< 100).

Hepatic Enzymes and Coagulation

GGT 25 U/L (9-36); ALP 82 U/L (40-150); AST 24 U/L (5-34); ALT 9 U/L (< 55); Total Bilirubin 0.6 mg/dL (0.2-1.2); INR 1.1; aPTT 31.2 secs (30.2); PT 11.6 secs (11.7).

Albumin and Proteins

Albumin 2.2 g/dL (3.4-4.8 g/dL), serum and urinary monoclonal protein IgA/κ; κ/λ 4.15 (1.17-2.93); Serum IgG 543 mg/dL (552-1631); IgA 102 mg/dL (69-517); IgM 34 mg/dL (33-293); C3 110 mg/dL (83-193); C4 24.5 mg/dL (15-57). Nephrotic proteinuria 5.5 g/day without albuminuria.

Other

β2-microglobulin 12 9 mg/L (< 4), LDH 219 U/L (125-220), CRP 65 mg/L (< 5 mg/L), ESR 52 mm/1st h (0-30), Ferritin 744.9 ng/mL (4.63-204.0), B12 Vitamin 430 pg/mL (189-883), Folic Acid 1.60 ng/mL (2.34-18.99).

ECG and Echocardiogram

ECG: sinus rhythm, right bundle branch block, low voltage of QRS complexes (< 1.0 mV in all precordial leads and < 0.5 mV in all limb leads). Echocardiogram: diastolic dysfunction; increased LV wall thickness (12 mm).

Electromyography

Reduced motor amplitude in all territories studied, with signs of active denervation; no sensitive changes.

Skeletal Xray

No evidence of lytic lesions or other fractures.

Bone Marrow Aspirate

Hypocellular bone marrow with 14% plasmocytes, of which 97% were abnormal.

Skin Biopsy

Chest wall (where it appeared more thickened):positive for cutaneous amyloidosis (apple-green birefringence with Congo red staining under polarized light) in the context of MM.

Other

Angio CT: no evidence of pulmonary embolism or organomegalies, apparent thickening of the chest wall; Bronchoscopy: no airway obstruction; Cerebral and cervical MRI: within normal; Spirometry: restrictive disease; Lumbar puncture: no cells, gluco or proteinorachia.

 

ALP: Alkaline phosphatase, ALT: Alanine aminotransferase, APTT: Activated partial thromboplastin time, ASP: Aspartate aminotransferase, BNP: Brain natriuretic peptide, CRP: C-reactive protein, CK: Creatinine kinase, ECG: Electrocardiogram, ERS: Erytrhocyte sedimentation rate, GGT: Gamma-glutamyltranspeptidase, Ig: Immunoglobulin, INR: International normalized ratio, LV: Left ventricular, MM: Multiple myeloma, PT: Prothrombin time, MRI: Magnetic resonance