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Healthy Older Man With Abnormal IgG Level

Healthy Older Man With Abnormal IgG Level

The results of a preoperative serum protein electrophoresis (SPEP) test were
abnormal in a 72-year-old man who underwent a successful hernia repair
2 weeks earlier.

HISTORY

The patient is healthy and has no chronic medical problems. He takes
ibuprofen and acetaminophen as needed for hip pain, which is worse on the left
side. He has no bone pain elsewhere and denies weakness, fatigue, and bleeding
symptoms, such as bruising. Review of systems is noncontributory.

PHYSICAL EXAMINATION

Blood pressure is 132/80 mm Hg. Mucous membranes are not pale, and
lymph nodes are not enlarged. Heart and lungs are normal. The herniorrhaphy
scar on the right is healing well. No bony tenderness is evident in the ribs,
spine, or pelvis on compression or percussion.

LABORATORY AND IMAGING RESULTS

Laboratory results from the preoperative and postoperative evaluations include
a white blood cell count of 8700/?L, with a normal differential; hemoglobin
concentration, 14.4 g/dL; and a normal platelet count. Serum chemistries
and serum albumin, calcium, creatinine, and alkaline phosphatase levels are
normal. The SPEP test shows a small monoclonal band, and immunoelectrophoresis
reveals an IgG band that measures 1198 mg/dL; IgM and IgA levels
are normal. Urinalysis and urine protein electrophoresis results are normal.
An MRI scan of the hips and pelvis reveals severe degenerative disease in both
hips, greater in the left than in the right, but no other bone pathology.

Which of the following is the most appropriate next step for this
patient?

A. Initiate therapy for multiple myeloma using melphalan and prednisone.
B. Order a bone marrow biopsy and aspiration for pathologic evaluation
and flow cytometry analysis.
C. Refer the patient for evaluation for autologous marrow transplantation
for multiple myeloma.
D. Reassure the patient that in most cases these types of protein abnormalities
resolve with time.
E. Arrange to follow the patient at 6- or 12-month intervals to monitor
SPEP levels.

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