Sorry for the delay in sending out the summary of
this case. Holidays and workload conspired against us!
Case 84:
Thanks to David G Williams for suggesting this
case.
A 17year old female presented to the
Casualty/Emergency Department of the Hospital with abdominal
pain.
Serum results are as follows:
Alkaline phosphatase: 214 IU/L (upto
230)
Total protein:
110 g/L (65- 85)
Albumin:
45
g/L (34 - 50)
Total
bilirubin:
7µmol/L (3 - 20)
Gamma GT:
25 IU/L (0 - 35)
AST: 34
IU/L(0 - 25)
ALT:
31 IU/L(0 - 25)
There were 35 participants in this case. There was a wide divergence of
views.
18 participants would not comment on these results until they had
electrophoresis or immunoglobulin results available. [-0.3]
12 stated high globulin due to infection and or
inflammation [1.0]
8 would add electrophoresis to check if
globulin increase was polyclonal or monoclonal before commenting. [-0.7]
10 participants would query fluid loss or dehydration. [0.3]
6 participants would contact the Doctor to discuss this case or request
further drug/ clinical history [1.7]
6 participants would query autoimmune cause of increased globulins
[-1.0]
5 would state note increased total protein; [-0.3]
3 participants would phone Doctor after results of
electrophoresis/ immunoglobulins [0]
4 would state that myeloma was unlikely in a young person;
[0.7]
3 would query increase globulins due to HIV; [-1.3]
3 would query ectopic pregnancy; [-1.7]
3 participants would not comment as medical staff should be able to
determine appropiate tests from this patient's history. [-1.3]
3 would look at the sample to check turbity/ haemolysis as this may
interfer in the assay. [1.3]
3 participant noted the slightly raised transaminases; one of these
queried hepatic cell damage. [0]
3 would query SLE; [0]
2 would query monoclonal increase in globulin due to myeloma or
Waldenstroms [ -0.7]
2 would suggest appendicitis should be ruled out; [0]
2 participants would query myeloma; [-0.7]
2 would query pancreatitis; [0.3]
2 suggested that high total protein could be due to interference in the
assay ; [0.7]
2 queried drug use. [-1.0]
2 would query if the tourniquet was on too long; [-1.3]
1 would check the age of the patient as myeloma is likely is patient aged
71yr instead of 17yr. [1.0]
1 queried porphyria; [-1.7]
1 suggested possibility of intra-uterine infection. [-0.7]
1 queried lymphoid tumour; [-0.7]
1 would advise that Addison's disease should be excluded;
[-0.7]
18 participants would add electrophoresis or electrophoresis + typing to
this sample. [1.0]
12 participants would add amylase [1.7]
11 would add urea & electrolytes [0.7]
9 participants would quantify the immunoglobulins; [1.7]
8 would add CRP [1.0]
8 would add or request pregnancy test/ serum or urine HCG; [0]
7 would check or repeat the total protein; [0.7]
6 would add ANA [-0.3]
5 would check FBC or WCC; [1.0]
5 would add serum calcium; [1.0]
3 would each add
glucose [0.3]
SLE screen [0]
2 would each add or request
plasma viscosity [1.0]
urine culture [0]
repeat LFT in 2-3 days [-0.3]
autoantibody screen [1.0]
repeat sample to confirm [0.7]
ESR [1.0]
1 would each add or request
rheumatoid factor [0]
drug screen [-1.7]
transvaginal ulrasound/ CT abdomen [-1.0]
urine specific gravity [-1.0]
The assessors particularly liked the comment to check the patient's age.
Nice one Graham!
David G Williams told us that their haematologist correctly suggested
the cause. The high total protein was in fact due to a polyclonal gammopathy
brought on by infection.
Best wishes
Jacqui Osypiw
Gordon
Challand