Figure 13.12 Rouleaux. Red cells form stacks of coins as a reaction to excess protein.

laboratory abnormalities such as rouleaux may also be seen. Red cells circulating in abnormal proteins like fibrinogen and globulin may cause rouleaux formation (Fig. 13.12), where red cells look like stacks of coins even in the thinner areas of the smear. Unlike red cell agglutination, where red cells are attracted to an specific antibody and appear in clumps, rouleaux is nonspecific binding of red cells where the net negative charge of red cells has been neutralized by excess protein (Fig. 13.13). Rouleaux may cause falsely decreased red counts and falsely increased MCV and MCHC. Red cell counts appear lower as the doublets and triplets caused by rouleaux pass through the red cell-counting aperture of automated equipment as one cell. MCV appears higher because the red cell volume is directly measured and red cells showing rouleaux appear larger. MCHC appears falsely increased because these parameters are calculated using red count. The peripheral smear may also show a blue coloration on macroscopic examination due to excess proteins. The ESR (refer to procedure section, Chapter 20) is usually elevated due to the increased settling of the red cells brought on the increased globulin content of the plasma (Table 13.6).

Bence Jones protein is a peculiar protein made by some individuals with MM as a result of an excess of kappa and lambda light chains. These light chains are small and can be filtered by the kidneys. They appear in the urine and have several unique properties. When urine is heated to 56°C, Bence-Jones protein precipitates out and will redissolve at higher temperature. As the urine is cooled, precipitates will once again appear, and will dissolve upon cooling. Bence-Jones protein is damaging to the kidneys.

Symptoms and Screening for Multiple Myeloma

Approximately 50,000 Americans are diagnosed with multiple myeloma each year.15 Symptoms usually do not develop initially, but as the numbers of plasma cells accelerate, the individual may experience the following:

• Excessive thirst and urination—due to excess calcium

• Nausea—due to excess calcium

• Bone pain in back and ribs—due to plasma cell acceleration

• Bone fractures—due to calcium leeching from bones into circulation

• Unexpected infections—due to compromised immunity

• Weakness and numbness in the legs—due to vertebrae compression

Screening and diagnosis of patients suspected of having MM include a CBC, possibly a bone marrow, urinalysis, and protein panel. Serum protein electrophoresis (SPE) and beta-microglobulin might also be ordered. Serum beta-microglobulin is a protein produced by the light chains. In the early stages of MM, this protein is at a low level. Elevated levels greater than 6 pg/mL are seen later in the disease and usually indicate higher tumor burden and poor prognosis.

Prognosis and Treatment in Multiple Myeloma

Patients with multiple myeloma face many difficulties especially with respect to their skeletal condition. Some individuals show punched-out lesions on initial radiographs. Chemotherapy and radiation may be used, with radiation providing some relief in painful bone areas. Agents used in chemotherapy include the gluco-corticoids and interferon-alfa, yet survival times from

Table 13.6 O Laboratory Findings of Multiple Myeloma

• Pancytopenia

• Abnormal serum electrophoresis

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