Hello,
I am in the process of sorting out what some test results mean and could use any help anyone can offer. I will try to be as clear as I can, but I'm still learning so I'm not sure I understand fully what I am asking. I ask your patience.
In late April 2013 I had my normal yearly blood work done during my annual physical. At the time of the yearly bloodwork, I also had a DTap booster.
The blood work showed:
RBC 4.11 (range 4.2-6.3) - low
HGB 10.3 (range 12-18) - low
HCT 31.5 (range 37-51) - low
MCV 76.6 (range 81-99) - low
MCH, 25.1 (range 26-33) - low
MCHC 32.7 (range 32-36) - normal
PLT 299 (range 140-440) - normal
Total Protein 7.67 (range 6.3-7.8) - normal
Calcium 8.7 (range 8.4-10.4) - normal
Creatinine .8 (range .8-1.2) - normal
on FE/TIBC profile
iron 16 (range37-139) - low
TIBC 462 (range 250-450) - high
%Sat 3 (range 20-55) - low
My doctor called to say I had iron deficiency anemia and ordered an endoscopy and colonoscopy. I had a clear endoscopy a couple weeks later (inflammatory fundic polyps were found which the GI doc said were a result of PPI use). I am having a colonoscopy to rule out bleeding this week.
In the meantime, after reading more about PPI use (which I have been on for 10 years), I suspected it could be causing part of my iron deficiency anemia so I reduced my dosing to once every 3 days. I also began eating meat (had been vegetarian), and added daily blackstrap molasses (high iron). I did this for approximately a month and then saw another doctor who ran blood work on 6/18/13. In addition to the standard BMP and CBC, the second doctor ordered what he listed as immunoglobulin pheresis because of my having talked to him about having had numerous colds/flu over the last 5 years, pneumonia (2011) and a campylobacter food poisoning (2012).
The results showed:
WBC & Lymphocytes subset all normal
RBC 4.39 (range 4.2-5.4) - now normal range
HGB 11 (range 12-16) - not normal, but up .7
HCT 34.7 (range 37-47) - not normal, but up 3.2
MCV 79.1 (range 81-101) - not normal, but up 2.5
MCH 25.1 (range 27-34) - not normal, same value as first test
MCHC 31.7 (range 31.5-36) - normal, also normal on first test
RDW 16.3 (range 10.5-14.3) - high - was not a value given on the first test
Reticulocyte count: 1.30 (range .5-1.5)
Calcium 9.1 (range 8.6-10.4) - normal
Creatinine .67 (range .5-1.1) - normal
No Total Protein given
Ferretin 6 (range 10-291).
Additionally, there were two immune related areas on the test which I think came from his request for immunoglobulin pheresis. One was not labelled with a title, but gave values of IgA 177 (range used 81-463), IgG 1416 (range used 694-1618) and IgM 120 (range used 48-271). Above that is a test called Immunofixation that states "IgG lambda monoclonal protein detected. Possible IgM kappa monoclonal protein detected." No values are given just the written interpretation.
So, I have a number of questions:
1. Do my results from 6/18/13 indicate that my body is responding to the changes I've made with the PPI and increased iron intake? Does this suggest that my anemia is most probably iron-deficiency anemia? Is the high-end value on the reticulocyte count indicating that my body is using my increased iron intake to rebuild my blood?
2. Is the big end of normal value in total IgG suggestive of being 6 weeks post Dtap booster when I had this blood draw? I have seen warning/precautions regarding immunophoresis that say to notify your doctor/lab prior to running these tests if you have had any immunizations/vaccinations within the last 6 months. I saw in something I read that the booster I had would have been peaking in antibody production at about 6-7 weeks (matches to my 6/18/13 blood draw).
3. Is Immunofixation a normal part of immunoglobulin pheresis or was it done because of the borderline high value of the IgG on the total IgG test? Or because of some other reason?
4. There is no value given for the amount of the M-protein(s?) so I don't know what the amount of it is(are). Is the value of a particular Ig M protein separate from the total IgG value? Meaning, if total IgG is 1400 is the M-protein some portion of that or is it its own value?
I am seeing a hematologist on Friday to ask my questions and likely have more tests.
My second doctor didn't seem worried about this and said he'd be surprised if this really were anything major. Is there anything in my above description that explains to you why he'd say that? I'm somewhat confused and scared.
Thanks in advance for any help.
C
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7 posts
• Page 1 of 1
Re: In process of diagnosis - unclear on test results
Hi There,
I will talk to part of your post, specifically:
Above that is a test called Immunofixation that states "IgG lambda monoclonal protein detected. Possible IgM kappa monoclonal protein detected." No values are given just the written interpretation.
Immunofixation is a qualitative test, not a quantitative test. That is, it will tell you if something is present, but not how much of it is present. It is a separate test from the ones that measure your specific immuogloblobuilin levels.
Based on the above, I would think it would be prudent to follow through with the following lab tests:
SPEP
Freelite Assay
UPEP
Beta2 Microglobulin
Once you've got these lab results in hand, you would have a better idea what you are dealing with and whether multiple myeloma might be involved.
See:
http://myeloma.org/ArticlePage.action?tabId=1&menuId=322&articleId=3177&aTab=-1
for an explanation.
Best of luck to you.
I will talk to part of your post, specifically:
Above that is a test called Immunofixation that states "IgG lambda monoclonal protein detected. Possible IgM kappa monoclonal protein detected." No values are given just the written interpretation.
Immunofixation is a qualitative test, not a quantitative test. That is, it will tell you if something is present, but not how much of it is present. It is a separate test from the ones that measure your specific immuogloblobuilin levels.
Based on the above, I would think it would be prudent to follow through with the following lab tests:
SPEP
Freelite Assay
UPEP
Beta2 Microglobulin
Once you've got these lab results in hand, you would have a better idea what you are dealing with and whether multiple myeloma might be involved.
See:
http://myeloma.org/ArticlePage.action?tabId=1&menuId=322&articleId=3177&aTab=-1
for an explanation.
Best of luck to you.
-
Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: In process of diagnosis - unclear on test results
Dear researcher13,
There is no question that iron deficiency is present and can certainly explain the low hemoglobin, low hematocrit, low MCV, low serum iron, high TIBC and low iron saturation. The slight increase of the hemoglobin and hematocrit on repeat testing would suggest that some of the changes you have made may be beginning to help. However, a ferritin of 6 is still quite low. I agree with the colonoscopy.
One of the reasons a quantitative value to this monoclonal IgG lambda was not provided may be due to the fact that it is too low to quantify. Without additional information, it is impossible to say. However, based on the work-up thus far, I would bet that this represents at most MGUS (monoclonal gammopathy of undetermined significance) and not multiple myeloma or other related disorder.
I agree with the hematology-oncology consultation. They will need to determine whether a monoclonal gammopathy (abnormal clonal antibody) is truly present or not. If so, additional testing to evaluate for multiple myeloma and other plasma cell disorders (e.g. amyloidosis) will be performed. The tests that Multibilly have suggested are a good start, but additional tests would also be required.
Let us know how things go. Take care!
Pete V.
There is no question that iron deficiency is present and can certainly explain the low hemoglobin, low hematocrit, low MCV, low serum iron, high TIBC and low iron saturation. The slight increase of the hemoglobin and hematocrit on repeat testing would suggest that some of the changes you have made may be beginning to help. However, a ferritin of 6 is still quite low. I agree with the colonoscopy.
One of the reasons a quantitative value to this monoclonal IgG lambda was not provided may be due to the fact that it is too low to quantify. Without additional information, it is impossible to say. However, based on the work-up thus far, I would bet that this represents at most MGUS (monoclonal gammopathy of undetermined significance) and not multiple myeloma or other related disorder.
I agree with the hematology-oncology consultation. They will need to determine whether a monoclonal gammopathy (abnormal clonal antibody) is truly present or not. If so, additional testing to evaluate for multiple myeloma and other plasma cell disorders (e.g. amyloidosis) will be performed. The tests that Multibilly have suggested are a good start, but additional tests would also be required.
Let us know how things go. Take care!
Pete V.
-
Dr. Peter Voorhees - Name: Peter Voorhees, M.D.
Beacon Medical Advisor
Re: In process of diagnosis - unclear on test results
Thank you Multibilly and Dr. V. for your swift and helpful responses.
I have a few followup questions.
1. Dr. V. said they will need to determine if a monoclonal gammopathy is truly present. How will they do that? Are there more specific results from the current test that they will need to review like the images of the bands/spikes themselves? Those weren't in the report copy that I saw. Should I be trying to request something from the lab to have for my meeting with the hematologist on Friday?
2. My transferrin was elevated in the first labs I had done (I assume this from the elevated TIBC value). I've read some about how it can cause a false positive if the amount of the M-protein is small and it co-migrates with the transferrin to the Beta region. Is this something I should specifically ask about and how would I best phrase the question?
Thank you in advance for your help.
Cindy
I have a few followup questions.
1. Dr. V. said they will need to determine if a monoclonal gammopathy is truly present. How will they do that? Are there more specific results from the current test that they will need to review like the images of the bands/spikes themselves? Those weren't in the report copy that I saw. Should I be trying to request something from the lab to have for my meeting with the hematologist on Friday?
2. My transferrin was elevated in the first labs I had done (I assume this from the elevated TIBC value). I've read some about how it can cause a false positive if the amount of the M-protein is small and it co-migrates with the transferrin to the Beta region. Is this something I should specifically ask about and how would I best phrase the question?
Thank you in advance for your help.
Cindy
Re: In process of diagnosis - unclear on test results
You can get false positive results, especially if the monoclonal protein migrates in the beta region. Your initial testing should indicate if one or the other monoclonal proteins identified migrated in this region. IgM monoclonal proteins often do.
I would repeat the SPEP and serum immunofixation to see if the first test was falsely abnormal. If persistently abnormal, additional work-up is indicated, which could include 24-hour urine protein electrophoresis and immunofixation, serum free light chain testing, beta2-microglobulin, CBC, chemistries (including calcium), albumin, liver tests, creatinine to assess kidney function, skeletal survey. Whether a bone marrow biopsy would need to be done depends on the results of the above work-up.
I suspect the worst case scenario is simply MGUS. I would be curious to find out if the "M-spikes" disappear after correction of your iron deficiency.
Keep us updated. Thanks!
Pete V..
I would repeat the SPEP and serum immunofixation to see if the first test was falsely abnormal. If persistently abnormal, additional work-up is indicated, which could include 24-hour urine protein electrophoresis and immunofixation, serum free light chain testing, beta2-microglobulin, CBC, chemistries (including calcium), albumin, liver tests, creatinine to assess kidney function, skeletal survey. Whether a bone marrow biopsy would need to be done depends on the results of the above work-up.
I suspect the worst case scenario is simply MGUS. I would be curious to find out if the "M-spikes" disappear after correction of your iron deficiency.
Keep us updated. Thanks!
Pete V..
-
Dr. Peter Voorhees - Name: Peter Voorhees, M.D.
Beacon Medical Advisor
Re: In process of diagnosis - unclear on test results
Hi Dr. Pete,
Thanks for your quick response once again. Your responses have helped ease my fear and prepare me better for my meeting with the hematologist on Friday. I'll let you know how things proceed.
Cindy
Thanks for your quick response once again. Your responses have helped ease my fear and prepare me better for my meeting with the hematologist on Friday. I'll let you know how things proceed.
Cindy
Re: In process of diagnosis - unclear on test results
My colonoscopy was normal. I met with the hematologist at Mass General on Friday. He had planned a bone marrow biopsy (I think from having talked to my doctor who probably indicated I was freaked out and am an information hound who would want all info I could get), but said that after looking at my charts, he couldn't justify doing the bone marrow test at this point given my values. Instead, he did another blood draw and had me book a return visit with blood work again in 4 months. He didn't seem overly worried and talked about 6 month monitoring and eventual 1-2 year monitoring if things remain stable.
The results have come in on the last blood work and now I have numbers on the IgG lambda and the IgM kappa. Here is the write up on that:
"Serum free lambda light chains are increased. There is a 0.42 g/dl IgG lambda M component in the gamma region and a 0.07 g/dl IgM kappa M component in the gamma region."
Additionally, they did sFLC testing which showed:
Kappa FLC (mg/L) 11.7 (normal range 3.3-19.4)
Lambda Free Light Chains (mg/L) 37.4 (normal range 5.7-26.3)
Kappa FLC/Lambda LC 0.3 (normal range .3-1.7)
The total gamma globulins were all slightly higher on this test than the first test, but also used different normal ranges than the original test (first test was done by Quest Diagnostics, this latest one was done at Mass General Hospital):
IgG 1483 (614-1295 mg/dl)
IgA 200 (69-309 mg/dl)
IgM 133 (53-334 mg/dl)
All my iron deficiency anemia related levels other than RDW and ferritin have come into normal range:
RBC: 4.63 (4.00-5.20 mil/cmm)
HGB: 12.3 (12.0-16.0 gm/dl)
HCT: 37.6 (36.0-46.0%)
PLT: 284 (150-400 th/cumm)
MCH: 26.6 (26.0-34.0 pg/rbc)
MCHC: 32.7 (31.0-37.0 g/dl)
RDW: 17 (11.5-14.5%)
Ferritin: 6 (10-200 ng/ml)
TIBC: 376 (230-404 mcg/dl)
Iron: 36 (30-160 mcg/dl)
Vitamin B12: 495 (>250 pg/ml)
The other levels remain normal (though BUN is slightly low). I do have one question on the following values (shouldn't the albumin plus the globulins be equal to the total protein?)
Total protein: 7.6 (6.0-8.3 g/dl)
Albumin: 4.6 (3.3-5.0 g/dl)
Globulin: 3.3 (2.3-4.1 g/dl)
BUN: 7 (8-25 mg/dl)
Calcium: 9.2 (8.5-10.5 mg/dl)
Creatintine: .74 (.60-1.50 mg/dl)
My hematologist put me on 220/5ML Liquid Ferrous Sulfate twice a day for the low ferritin. He didn't mention us talking about these test results before my return for the follow up in November so I could call to check on them or assume that if something were concerning, he'd contact me to get me to come back in earlier. I'm not sure what to do there.
My questions are:
1. Are the levels of the M proteins considered MGUS levels? There was some more generic writeup with these levels that talked about low level concentrations showing up after treated multiple myeloma, and a list of other conditions that show low level proteins (including other unusual forms of multiple myeloma - IgD and light chain version). It also said that MGUS was usually in concentrations of .5 to 3 grams per dl. If the levels are lower than that, do they look at other causes or is it still MGUS?
2. I know Dr. Pete said he was curious whether the spikes disappear when my iron deficiency is corrected. Is my iron deficiency still considered present since my ferritin is low even though the other values are now in normal range? Since the M proteins are in the gamma zone, I assume the elevated transferrin was not causing a false-positive. Are there other ways in which an iron-deficiency can cause transient M proteins?
3. I am not sure how to ask this question, so I will word it as best I can. I understand that a monoclonal protein is never normal. What I don't understand is how a booster shot which would elicit an antigen specific response would appear on immunofixation. I think I understand that the way the test works is that a monoclonal peak shows up because all the monoclonal protein migrates to exactly the same place. What I don't understand is how a booster shot immune response would look on immunofixation? While not monoclonal, would it be as polyclonal-ish as a primary immune response or would it be more monoclonal like (being that it is antigen-specific and calling up specific memory b cells) and cause some sort of peak...not a narrow peak, but sort of a more broad peak? I ask because I had a DTaP booster at the end of April and I’ve seen mentions of notifying the lab/doctor if you’ve had an immunization (especially a booster) in the last 6 months. I’m not clear if that precaution is mentioned only because it elevates the total amount of Ig or because it can mimic a monoclonal response as well.
Thanks for your patience with all my questions.
Cindy
The results have come in on the last blood work and now I have numbers on the IgG lambda and the IgM kappa. Here is the write up on that:
"Serum free lambda light chains are increased. There is a 0.42 g/dl IgG lambda M component in the gamma region and a 0.07 g/dl IgM kappa M component in the gamma region."
Additionally, they did sFLC testing which showed:
Kappa FLC (mg/L) 11.7 (normal range 3.3-19.4)
Lambda Free Light Chains (mg/L) 37.4 (normal range 5.7-26.3)
Kappa FLC/Lambda LC 0.3 (normal range .3-1.7)
The total gamma globulins were all slightly higher on this test than the first test, but also used different normal ranges than the original test (first test was done by Quest Diagnostics, this latest one was done at Mass General Hospital):
IgG 1483 (614-1295 mg/dl)
IgA 200 (69-309 mg/dl)
IgM 133 (53-334 mg/dl)
All my iron deficiency anemia related levels other than RDW and ferritin have come into normal range:
RBC: 4.63 (4.00-5.20 mil/cmm)
HGB: 12.3 (12.0-16.0 gm/dl)
HCT: 37.6 (36.0-46.0%)
PLT: 284 (150-400 th/cumm)
MCH: 26.6 (26.0-34.0 pg/rbc)
MCHC: 32.7 (31.0-37.0 g/dl)
RDW: 17 (11.5-14.5%)
Ferritin: 6 (10-200 ng/ml)
TIBC: 376 (230-404 mcg/dl)
Iron: 36 (30-160 mcg/dl)
Vitamin B12: 495 (>250 pg/ml)
The other levels remain normal (though BUN is slightly low). I do have one question on the following values (shouldn't the albumin plus the globulins be equal to the total protein?)
Total protein: 7.6 (6.0-8.3 g/dl)
Albumin: 4.6 (3.3-5.0 g/dl)
Globulin: 3.3 (2.3-4.1 g/dl)
BUN: 7 (8-25 mg/dl)
Calcium: 9.2 (8.5-10.5 mg/dl)
Creatintine: .74 (.60-1.50 mg/dl)
My hematologist put me on 220/5ML Liquid Ferrous Sulfate twice a day for the low ferritin. He didn't mention us talking about these test results before my return for the follow up in November so I could call to check on them or assume that if something were concerning, he'd contact me to get me to come back in earlier. I'm not sure what to do there.
My questions are:
1. Are the levels of the M proteins considered MGUS levels? There was some more generic writeup with these levels that talked about low level concentrations showing up after treated multiple myeloma, and a list of other conditions that show low level proteins (including other unusual forms of multiple myeloma - IgD and light chain version). It also said that MGUS was usually in concentrations of .5 to 3 grams per dl. If the levels are lower than that, do they look at other causes or is it still MGUS?
2. I know Dr. Pete said he was curious whether the spikes disappear when my iron deficiency is corrected. Is my iron deficiency still considered present since my ferritin is low even though the other values are now in normal range? Since the M proteins are in the gamma zone, I assume the elevated transferrin was not causing a false-positive. Are there other ways in which an iron-deficiency can cause transient M proteins?
3. I am not sure how to ask this question, so I will word it as best I can. I understand that a monoclonal protein is never normal. What I don't understand is how a booster shot which would elicit an antigen specific response would appear on immunofixation. I think I understand that the way the test works is that a monoclonal peak shows up because all the monoclonal protein migrates to exactly the same place. What I don't understand is how a booster shot immune response would look on immunofixation? While not monoclonal, would it be as polyclonal-ish as a primary immune response or would it be more monoclonal like (being that it is antigen-specific and calling up specific memory b cells) and cause some sort of peak...not a narrow peak, but sort of a more broad peak? I ask because I had a DTaP booster at the end of April and I’ve seen mentions of notifying the lab/doctor if you’ve had an immunization (especially a booster) in the last 6 months. I’m not clear if that precaution is mentioned only because it elevates the total amount of Ig or because it can mimic a monoclonal response as well.
Thanks for your patience with all my questions.
Cindy
7 posts
• Page 1 of 1