Urine protein electrophoresis showed a band of restricted mobility in the globulin region. the underlying cause, is crucial as delay in treatment can have devastating consequences. Case presentation A 76-year-old Peruvian man presented to the emergency department for evaluation of one month of gradual onset of lower extremity weakness resulting in falls. He also reported a two day history of bladder and bowel incontinence. A systemic review of our patient was notable for dull but intense chronic back pain. He was no longer ambulatory, had lower extremity numbness and tingling, and had experienced an unspecified amount of weight loss over the last six months. A systemic review of our patient was otherwise unremarkable. Our patient had emigrated from Peru to the United States seven years prior to this admission and had not been seen by a physician until the current admission. His medical history was significant for iron deficiency anemia, a cholecystectomy (reason unknown), a hernia repair, and a prostatectomy one year prior to his emigration to the United States. The prostatectomy was reported to be for symptomatic benign prostatic hypertrophy. Physical examination of our patient revealed the absence of bilateral lower extremity reflexes, lower extremity weakness (one out of five), upper extremity weakness (three out of five), mild saddle anesthesia and tenderness along his spine. Sensation to pain and temperature, as well as proprioception, was absent in his Mouse monoclonal to MYH. Muscle myosin is a hexameric protein that consists of 2 heavy chain subunits ,MHC), 2 alkali light chain subunits ,MLC) and 2 regulatory light chain subunits ,MLC2). Cardiac MHC exists as two isoforms in humans, alphacardiac MHC and betacardiac MHC. These two isoforms are expressed in different amounts in the human heart. During normal physiology, betacardiac MHC is the predominant form, with the alphaisoform contributing around only 7% of the total MHC. Mutations of the MHC genes are associated with several different dilated and hypertrophic cardiomyopathies. lower extremities. Aside from mild paresthesia, sensation in his upper extremities was intact. Other findings on physical examination were unremarkable. Other than his hemoglobin of 12.1 g/dL (normal range is 13.5 to 17.5 g/dL) and a mildly elevated BUN-to-creatinine ratio at 28 mg/dL (normal range is 7 to 18 mg/dL) to 1 1.2 mg/dL (normal range is 0.6 to 1 1.2 mg/dL), our patient’s laboratory values were within normal limits. Results for corrected serum calcium and coagulation studies were normal. His total protein level was 5.8 g/dL (normal range = 6 to 8 8 g/dL), and his albumin level was 3.2 g/dL (normal range is 3.5 to 5 g/dL). His Btk inhibitor 1 alkaline phosphatase was 142 U/L (normal range is 40 to 125 U/L). Radiographic studies on admission included a normal chest radiograph and a normal non-contrast computed tomography (CT) scan of his brain. Magnetic resonance imaging (MRI) with gadolinium of his lumbar spine showed both left-sided L2-3 and right-sided L4-5 degenerative disc disease with protrusion into the neural foramen and multiple foci of abnormal bone marrow signal enhancement. A subsequent MRI of his cervical spine showed a large mass at the cervicothoracic junction extending from C7 to T1, bony destruction of three vertebral bodies and epidural extension causing severe spinal cord compression and cord edema. CT scans of his neck, thorax and abdomen did not identify a Btk inhibitor 1 primary neoplasm, but did note the cervical mass with nodular hemorrhagic areas and numerous well-defined lytic lesions of his axial and appendicular skeleton and ribs. Common tumor markers (CEA, CA 19-9, and PSA) were found to be normal. Serum protein electrophoresis demonstrated hypoproteinemia with hypoalbuminemia and borderline low gamma globulins. Urine protein electrophoresis showed a band of restricted mobility in the globulin region. Immunofixation revealed monoclonal light chains. On examination, a pathological specimen obtained through CT-guided biopsy revealed soft tissue necrosis and sheets of mature plasma cells. The cells stained positive for CD138 and CD79a, thus confirming plasma cell lineage. Bone marrow aspirate displayed a focally hypercellular bone marrow with Btk inhibitor 1 mild trilinear hyperplasia, mild to moderate plasmacytosis (5% to 20%) and iron changes consistent with a state of chronic disease. These results, together with protein electrophoresis and radiographic images, confirmed the diagnosis of multiple myeloma. Discussion This case presented a challenge in that our patient’s initial presentation had a preponderance of lower extremity symptoms compared to upper extremity symptoms. Thus, his pretest probability was highest for conditions affecting the lumbar spine, such as cauda equine syndrome from disc herniation or metastatic disease. Btk inhibitor 1 The initial MRI of his lumbar spine in fact confirmed disc herniation with protrusion, but the abnormal bone marrow signal.
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