Biomedical subjects
Publications and source records attributed to David Sinclair.
The relationship between serum paraprotein and beta2-microglobulin (B2m) levels was studied in serial samples from 41 patients with myeloma. A positive correlation coefficient was found in 70.7% of myeloma patients indicating that no extra information was gained from measuring both analytes routinely. As a result, the workload for B2m fell without any diminution in clinical service.
BACKGROUND: Guidelines suggest that duodenal biopsies should be taken in patients with iron deficiency anaemia. OBJECTIVE: To examine anti-endomysial antibody (anti-EMA) and duodenal biopsy testing in Portsmouth, UK. To evaluate if the current pathology workload can be reduced by anti-EMA replacing some duodenal biopsies. To determine to what extent doctors in Portsmouth are confirming a positive anti-EMA test by small bowel biopsy. DESIGN: Patients' records were examined firstly from whom duodenal biopsies were taken between April 1999 and September 2000, and secondly who had anti-EMA tested between December 1999 and September 2000. SETTING: Queen Alexandra Hospital, UK. District General Hospital. Medical Outpatients Department. RESULTS: In the first group, of 354 patients undergoing duodenal biopsy, 108 patients had anti-EMA tested. Of these 108 patients, 25 had positive IgA anti-EMA and 83 had negative IgA anti-EMA. Of these 83 patients who had negative IgA EMA, 8 patients had a duodenal biopsy suggestive of Coeliac Disease. 4 of these 8 patients were on gluten free diets at the time of anti-EMA testing so were excluded. 1 of the 4 patients who had a duodenal biopsy indicative of Coeliac Disease had a positive IgG anti-EMA despite negative IgA anti-EMA. Therefore 3 false negative IgG anti-EMA were ultimately identified giving a sensitivity of 89% and a specificity of 100%. On follow up one has subsequently been found to have T-cell lymphoma; if this patient is taken into account the sensitivity of anti-EMA increases to 93%. In the second group; 1450 patients had anti-EMA tested. Of the 67 positive anti-EMA tests in this group only 12 had a duodenal biopsy. CONCLUSIONS: Many patients who have been tested for anti-EMA are not offered duodenal biopsy in Portsmouth despite current British Society of Gastroenterology (BSG) guidelines, although it should be noted that the BSG guidelines on iron-deficiency anaemia recommend using anti-EMA without histology to exclude Coeliac Disease in menstruating women (biopsy would still be recommended if anti-EMA were positive). Our study has found a high sensitivity and specificity of anti-EMA; there may therefore be some circumstances where duodenal biopsy is unnecessary in the investigation of Coeliac Disease. Patients with suspected Coeliac Disease and negative anti-EMA should be evaluated for other causes of villous atrophy.
Raised serum bilirubin is a common finding as part of a routine "liver function test" profile. This case describes a patient with a raised serum bilirubin that was eventually found to be caused by intravascular haemolysis. The tests that confirmed the cause were instigated by clinical biochemistry staff but not before the patient had undergone unnecessary invasive procedures and had the diagnosis delayed by some time. The case is a reminder to biochemistry and haematology laboratories and clinical staff to investigate the possibility of haemolysis as well as hepatitis and Gilbert's disease as a cause of an isolated raised bilirubin.
The study of IgD myeloma remains a challenging field. In terms of the initial detection of the IgD paraprotein, great care must be exercised in the interpretation of electrophoresis patterns and immunoglobulin profiles. Laboratory staff have a very important role to play in this, as it is likely that many IgD myeloma cases are uncovered following the involvement of laboratory staff. They must help to ensure that suggestive electrophoresis and immunoglobulin levels are properly investigated and that Bence Jones myeloma is not diagnosed without excluding the presence of an IgD paraprotein. In clinical terms, IgD myeloma remains a rare but aggressive tumour affecting younger people and with presenting features that include most of those common to all myeloma cases. However, renal problems, amyloidosis and the occurrence of Bence Jones lambda light chain proteinuria complicate matters to a far greater extent than in most other forms of the disease. There are now increasing numbers of case reports describing patients with associative symptoms and only time will tell whether these relationships are predictive or useful in nature. It is important however, given the rarity of the condition, that these cases continue to be reported. There do not appear to be any treatment regimes that are specifically tailored for IgD myeloma and the response to chemotherapy does not seem to differ from other forms of the disease. However, the management of any associated renal failure will always remain a challenge, I suspect. The progress being made in the treatment of myeloma as a whole, is bound to have a positive impact on the treatment of IgD myeloma.
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