Hematology Myeloma and Related Disorders: Review Questions Richard S. Stein, MD, FACP Dr. Stein is a Professor of Medicine, Vanderbilt University Medical Center, Nashville, TN. Choose the single best answer for each question.
	1. A 66-year-old man with cirrhosis comes to the primary care clinic because of back pain. He has had numerous falls because of his alcoholism. Radiographs show wedging of L4 and L5 vertebrae but no lytic lesions. Hematology and chemistry studies reveal a mild normochromic normocytic anemia. Bilirubin level is 1.2 mg/dL and aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase levels are normal. Albumin level is 2.8 g/dL and the globulin is 5.3 g/dL. A serum protein electrophoresis shows a polyclonal increase of gamma globulin. Which of the following is the most likely diagnosis for this patient? Myeloma Monoclonal gammopathy of unknown significance (MGUS) Either myeloma or MGUS Neither myeloma nor MGUS Click here to compare your answer. 2. A 57-year-old man is seen in the renal clinic for anemia, hematocrit of 34%, and proteinuria of 3 g/day. His creatinine level is 2.0 g/dL. Obtained as part of the work-up for renal failure, serum protein electrophoresis reveals a small monoclonal protein spike estimated as 0.2 g/dL. Urine protein electrophoresis is normal; the protein is all albumin with no monoclonal protein. Quantitative immunoglobulin results reveal: IgG, 1900 mg/dL (normal, 596-1744 mg/dL); IgA, 500 mg/dL (normal, 56­330 mg/dL); and IgM, 250 mg/dL (normal, 54-260 mg/dL). A bone marrow examination shows normocellular marrow with normal myeloid and erythroid maturation and approximately 5% plasma cells. No clumps of plasma cells are seen. Skeletal survey reveals no lytic lesions. Which of the following is the most likely diagnosis for this patient? Myeloma MGUS Either myeloma or MGUS Neither myeloma nor MGUS Click here to compare your answer.		3. A 50-year-old man presents to the emergency department for right hip pain. A radiograph reveals a lytic lesion of the right femur with impending fracture. He is sent to the operating room to have a pin placed in the femur. Biopsy of the lytic area shows sheets of plasma cells. History and physical examination are within normal limits except for the right hip. Laboratory studies include a hematocrit of 41%, a leukocyte count of 4.8 × 103/mm3 with a normal differential, and a platelet count of 340 × 103/mm3. Electrolytes, calcium and albumin levels, and results of renal and liver function studies are normal. A skeletal survey reveals no other lytic lesions. Bone marrow biopsy is normal. Serum protein electrophoresis reveals a monoclonal spike. Quantitative serum immunoglobulin levels are: IgG, 2400 mg/dL (normal, 596- 1744 mg/dL); IgA, 500 mg/dL (normal, 56- 330 mg/dL); and IgM, 250 mg/dL (normal, 54-260 mg/dL). Which of the following is the most likely diagnosis for this patient? Myeloma MGUS Either myeloma or MGUS Neither myeloma nor MGUS Click here to compare your answer. 4. A 50-year-old woman is evaluated for fatigue. Physical examination is unremarkable. She has a hematocrit of 31%, leukocyte count of 6.4 × 103/mm3 with normal differential, platelet count of 210 × 103/mm3, and 1.2% reticulocytes. Sodium, potassium, chloride, and bicarbonate levels are normal. Blood urea nitrogen is 50 mg/dL, and serum creatinine is 3.1 mg/dL. Albumin is 3.5 g/dL. Globulin is 2.6 g/dL. Calcium is 12.4 g/dL. Bilirubin and hepatic enzyme levels are normal. Serum protein electrophoresis is normal, but a urine protein electrophoresis shows a monoclonal spike identified as kappa chains. Quantitative serum IgG, IgA, and IgM results are normal. Skeletal survey shows lytic lesions in the right humerus, the right and left femur, and the skull. The bone marrow shows 60% plasma cells with many large clumps of plasma cells. The plasma cells are monoclonal and contain kappa light chains. Which of the following is the most likely diagnosis for this patient? Myeloma MGUS Either myeloma or MGUS Neither myeloma nor MGUS Click here to compare your answer.
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