58-year-old nuclear power plant worker presented to his family physician complaning of increasing fatigue and weakness. He also reported pain in his lower back and arms when he walks. Physical examination revealed pale mucous membranes and hepatosplenomegaly. The physician ordered a complete blood count (CBC) and urinalysis (UA). A follow-up appointment was scheduled for the following week.
Laboratory Data:
The CBC revealed that the patient had anemia. His leukocyte count and differential count were normal, except for a rouleaux (rolled coin) appearance of the RBCs. The UA was normal. The patient was called and requested to return to the laboratory for additional tests. The physician ordered an ESR, kidney screening profile, liver blood profile, and radiographic skeletal survey, with the following results:
• ESR—50 mm/hr
• Kidney profile—normal
• Liver profile—normal, except for increased globular protein
• Skeletal survey—bone lesions in various sites
Questions:
1. What follow-up laboratory tests might be ordered to assist in establishing a definitive diagnosis?
2. What is the nature of the urine protein found in this disorder ?
3. What is the most significant laboratory finding in this disorder?
4. What type of immunologic defect exists in this disease process?
5. Does this patient have a risk of occupational exposure?
The rouleaux (rolled coin) appearance of the RBCs is found in certain immunological diseases, multiple myeloma, other cancers, and connective tissue disorders. Although the leukocyte, differential count and UA were normal performing there might be a deficiency in Vit B12 and hence the patient was anemic.
The follow-up laboratory tests would help in understanding the quality of RBC by ESR, the kidney and liver blood profile would tell about the RBC turnover and serum protein quality estimation. The normal kidney profile suggests UA to be normal.
A skeletal survey followed by X-ray and MRI would be the most significant laboratory diagnostic tests. Further, by performing electrophoresis and speculating the number of bands obtained the type of antibody (IgG, IgA, and IgM) involved can be accessed.
Considering the nature of work done by the patient, there could be a risk of occupation on the patient’s health.
58-year-old nuclear power plant worker presented to his family physician complaning of increasing fatigue and weakness....
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