Clinical case history
The value of sFLC analysis for monitoring in a case of Waldenström's macroglobulinemia with a type 1 cryoglobulin.
An 82-year-old male with chronic kidney disease (stage 3) and diabetes was referred to the haematology department by his general practitioner based on results of routine investigations . These revealed that he was anaemic (haemoglobin 8.9 g/dL) and had an elevated plasma viscosity (15 cp) with a serum total protein of 102 g/L.
SPE revealed a monoclonal protein which was typed as an IgMλ, but this could not be accurately quantified as it precipitated out in the gel (Figure 32.4A). Furthermore, the serum sample appeared clotted after being stored at 4 °C, which was reversed once the sample was warmed to 37 °C, consistent with the presence of a cryoglobulin.
Haematological assessment highlighted symptoms which were consistent with hyperviscosity syndrome. These included dyspnoea, epistaxis, blurring of vision and sensory neuropathy, requiring plasma exchange. Although a diagnosis of WM was now expected, a rare case of IgM multiple myeloma could not be ruled out. A bone marrow aspirate was inconclusive but a trephine biopsy and immunohistochemistry confirmed the diagnosis of WM.
Cryoglobulin analysis confirmed the presence of a type 1 cryoglobulin (Figure 32.4B). The patient started a course of chemotherapy, and serial measurements of sFLCs were used to assess response (Figure 32.5).