serum protein electrophoresis

1. MONOCLONAL
HYPERGAMMAGLOBULINEMIA
Dr.Ghulam Murtaza
Resident chemical pathology

2. Out lines
■ Normal serum protein electrophoresis
■ Indication of SEP
■ Causes of increase /decrease in plasma proteins
■ cases

3. Serum protein electrophoresis
■ Simple ,easy ,inexpensive method of separating proteins based on
their net charge, size & shape
■ The two major types of proteins are present in serum are ALBUMIN &
GLOBULIN
■ Albumin is the major protein component of serum & represents the
largest peak that lies closet to positive electrodes
■ Globulin make up a much smaller fraction of total serum protein but
represents the primary focus of interpretation of SEP (Medscape )

4. Five groups are seen

6. Indications for Serum Protein
Electrophoresis
■ Suspected multiple myeloma,Walden Strom's macroglobulinemia, primary
amyloidosis,
■ Unexplained peripheral neuropathy (not attributed to longstanding diabetes
mellitus, toxin exposure, chemotherapy, etc.)
■ New-onset anemia associated with renal failure or insufficiency and bone pain
■ Back pain ,Hypercalcemia attributed to possible malignancy (e.g., associated
weight loss, fatigue, bone pain, abnormal bleeding)
■ Rouleaux formations noted on peripheral blood smear
■ Renal insufficiency with associated serum protein elevation Unexplained
pathologic fracture or lytic lesion identified on radiograph & Bence Jones
proteinuria
(Understanding and Interpreting Serum Protein Electrophoresis )

7. Albumin
■ Albumin is synthesized by liver at rate of 200mg/kg/dl (10-18g /day in 70kg
adult) Half life of albumin is 21 days, degradation occurs in capillary
endothelial cells
■ Important carrier of various plasma constituents like ,Calcium ,Magnesium,
thyroid hormones , unconjugated bilirubin ,fatty acids & some drugs
■ Water overload ,sample from I/v infusion, pregnancy ,malnutrition
,malabsorption ,Cirrhosis, burns ,& nephrotic syndrome leads to
hypoalbuminemia

9. ■ Increased alpha1 globulins Decreased alpha1 globulins
■ Pregnancy, acute inflammation Alpha1-antitrypsin deficiency
■ Increased alpha2 globulins
Adrenal insufficiency, Adrenocorticosteroid therapy ,diabetes mellitus, Nephrotic syndrome
■ Decreased alpha2 globulins
Malnutrition Megaloblastic anemia Protein-losing enteropathies Severe liver diseaseWilson’s disease
■ Increased gamma globulins
Amyloidosis, Chronic infections (granulomatous diseases), Chronic lymphocytic leukemia Cirrhosis
Hodgkin’s disease Malignant lymphoma Multiple myeloma Rheumatoid and collagen diseases Walden
Strom's macroglobulinemia

10. Polyclonal hypergammaglobulinemia
■ polyclonal gammopathies may be caused by any reactive or
inflammatory process, and they usually are associated with
nonmalignant conditions.
■ Predominantly IgG ; SLE ,Chronic active hepatitis
■ Predominantly IgA ; cryptogenic cirrhosis ,Crohn's disease ,TB
,Sarcoidosis
■ Predominantly IgM ; PBC & Parasitic infection

11. Monoclonal hypergammaglobulinemia
■ It’s a condition in which only one clone of B lymphocyte which proliferate
,produce the single offending immunoglobulin ( also called paraprotein/ M
protein) in excess .
■ The results in discrete ,well demarcated, band of protein in globulin area of
electrophoretogram
■ The M protein may be recognized as IgG,IgA,E & depending on heavy chain class
■ the light chain protein may be designated as kappa or lambda ,they may
precipitate & deposit producing organ damage

12. Multiple myeloma
■ This condition is due to abnormal proliferation of plasma cells (myeloma)
■ M protein appears as a narrow spike in the gamma, beta, or alpha2 regions.
■ M-protein level is usually greater than 3 g per dL.
■ Skeletal lesions (e.g., lytic lesions, diffuse osteopenia, vertebral compression fractures)
are present in 80 percent of patients.
■ Diagnosis requires 10 to 15 percent plasma cell involvement on bone marrow biopsy.
■ Anemia, pancytopenia, hypercalcemia, hyperuricemia and renal disease may be
present.

13. ■ Serum protein electrophoresis :
■ 80% have high total serum protein level & a monoclonal paraprotein band in
protein pattern ,
■ Secreted paraprotein are IgG in 55% ,IgA 25% ,IgD 1% & IgM o.1% pf myeloma
patient
■ Almost 20% do not have demonstrable band in serum pattern because due to light
chain production (being a small MW they filter through glomerular membrane
appear as Bence-johns protein in urine
■ Urine protein electrophoresis will reveal their presence & minimize the missed
diagnosis

15. Variants of multiple myeloma
■ Monoclonal gammopathy of undetermined significance
■ M-protein level is less than 3 g per dL.
■ There is less than 10 percent plasma cell involvement on bone marrow biopsy.
■ Affected patients have no M protein in their urine, no lytic bone lesions, no anemia, no
hypercalcemia, and no renal disease

16. ■ Smoldering multiple myeloma
■ M-protein level is greater than 3 g per dL.
■ There is greater than 10 percent plasma cell involvement on bone marrow biopsy.
■ Affected patients have no lytic bone lesions, no anemia, no hypercalcemia, and no renal disease
■ Walden Strom’s macroglobulinemia
■ IgM M protein is present. Affected patients have hyper viscosity and hypercellular bone marrow
with extensive infiltration by lymph plasma cells..
■ Heavy chain disease , Plasma cell leukemia

18. CASE –ONE ANS
■ AWELL DEFINED BAND IS SEEN IN
GAMMA GLOBULIN REGION .
■ SUGGESTIVEOF MONOCLONAL
GAMMOPATHY
■ SERUM IMMUNOGLUBULIN
QUANTIFICATION ,SERUM
IMMUNOFIXATION ,SKELETAL
SURVEY & BONE MARROW BIOPSY
ARE ADVICED

20. CASE 2 ANS
■ MARKED HYPOALBUMINEMIA ,
MILD DECREASE IN BETA
FRACTION
& MARKED
HYPERGAMMAGLOBULINEMIA
ARE NOTED

22. ■ A suspicious faint band is seen in
Beta region
■ Repeat the test after 4-6 weeks

23. ■ Thanks