A case with prolonged bacterial infection accompanied by an abnormal serum protein which migrated in the post-gamma region on electrophoresis is presented. The abnormal protein was identified as IgG with gamma-type light chain moiety. The patient suffered from prolonged pneumonia and cholecystitis, Bone marrow aspiration and skeletal x-rays did not indicate multiple myeloma.</p

Arima, Terukatsu

Gyoten, Yozo

Imai, Masanobu

Kita, Showichi

Nagata, Kowichi

Tanigawa, Takashi

Tsuboi, Shuhei

Okayama University Scientific Achievement Repository

Acta Medica OkayamaVolume 30, Issue 3 1976 Article 6JUNE 1976An extremely basic monoclonal IgG in anaged apoplectic patient with prolongedbacterial infectionTerukatsu Arima∗ Shuhei Tsuboi† Kowichi Nagata‡Yozo Gyoten∗∗ Takashi Tanigawa††Masanobu Imai‡‡ Showichi Kita§∗Okayama University,†Mitoyo General Hospital,‡Mitoyo General Hospital,∗∗Mitoyo General Hospital,††Mitoyo General Hospital,‡‡Mitoyo General Hospital,§Okayama University,Copyright c©1999 OKAYAMA UNIVERSITY MEDICAL SCHOOL. All rights reserved.An extremely basic monoclonal IgG in anaged apoplectic patient with prolongedbacterial infection∗Terukatsu Arima, Shuhei Tsuboi, Kowichi Nagata, Yozo Gyoten, TakashiTanigawa, Masanobu Imai, and Showichi KitaAbstractA case with prolonged bacterial infection accompanied by an abnormal serum protein whichmigrated in the post-gamma region on electrophoresis is presented. The abnormal protein wasidentified as IgG with gamma-type light chain moiety. The patient suffered from prolonged pneu-monia and cholecystitis, Bone marrow aspiration and skeletal x-rays did not indicate multiplemyeloma.∗PMID: 136872 [PubMed - indexed for MEDLINE] Copyright c©OKAYAMA UNIVERSITYMEDICAL SCHOOLActa Med. Okayama 30,209-214 (1976)AN EXTREMELY BASIC MONOCLONAL IgG IN AN AGEDAPOPLECTIC PATIENT WITH PROLONGEDBACTERIAL INFECTIONTerukatsu ARIMA, Shuhei TSUBOI*, Kowichi NAOATA*, Yozo GYOTEN*,Takashi TANIGAWA*, Masanohu IMAI* and Showichi KITAFirst Department of Internal Medicine (Director: Prof. K. Kosaka), OkayamaUniversity Medical School, Okayama 700, and"Mitoyo General Hospital,Toyohama, Kagawa 769, JapanReceived for publication, February 24, 1976Abstract. A case with prolonged bacterial infection accompaniedby an abnormal serum protein which migrated in the post-gammaregion on electrophoresis is presented. The abnormal protein wasidentified as IgG with A-type light chain moiety. The patient sufferedfrom prolonged pneumonia and cholecystitis. Bone marrow aspira-tion and skeletal x-rays did not indicate multiple myeloma.Detection of dysproteinemia has been facilitated by widespread use ofserum paper electrophoresis as routine laboratory procedure. Many instancesare found with the homogeneous peak characteristics of multiple myeloma.Only a few of these cases would be expected to have multiple myeloma (1) .Other cases of such abnormal proteins without skeletal lesion or bone marrowabnormality were classified as asymptomatic idiopathic paraimmunoglobulinemia(1), dysgammaglobulinemic syndrome (2), non-myelomatous paraproteinemia(3), or benign monoclonal gammopathy (4).Gammaglobulins which appear as a monoclonal globulin peak on electro-phoresis have been used to elucidate the structural specificity against the antigen.This paper describes a patient with an extremely basic monoclonal IgGwithout clinical manifestations associated with multiple myeloma or macro-globulinemia.CASE REPORTA 63-year-old farmer was admitted to the Mitoyo General Hospital onMarch 4, 1975, because of coma. Monoparesis of the left leg developed 2 daysprior to the admission, but the patient had clear -consciousness at that time. Onthe day of admission, his family found him in deep sleep. He was brought tothe hospital.On admission he was almost comatose with a temperature of 37.8°C, bloodpressure l42/80mm Hg, pulse rate 78 beats/min and respiratory rate 16/min.2091Arima et al.: An extremely basic monoclonal IgG in an aged apoplectic patientProduced by The Berkeley Electronic Press, 1976210 T. ARIMA et at.His left arm and left leg were flaccid. The spinal fluid was bloody, and cere-bral angiograms revealed narrowing of the right anterior artery. The rightlenticulo-striate artery, right middle cerebral artery and pericallosal arterywere slightly depressed to the base of the brain. Chest roentgenograms takenNORMALPATIENTtFig. 1. Elecrophoretic patterns of serum on cellulose acetate membrane. Notean abnormal band (arrow) in the post-gamma-region. Anode is on the left.NORMAL •PlmENT'~PATIENTNORMALFig. 2. Agar gel electrophoresis and immunoelectrophoresis developed withantigen serum to whole human serum. A, Agar gel electrophoresis. The arrowshows an abnormal band in the post-gamma-region. B, Immunoelectrophoresis.The arrow shows an abnormal precipitation are in the post-gamma-region. Anodeis on the left.2Acta Medica Okayama, Vol. 30 [1976], Iss. 3, Art. 6http://escholarship.lib.okayama-u.ac.jp/amo/vol30/iss3/6Extremely Basic IgG in Bacterial Infection 211on the same day disclosed bilateral pneumonia. The electroencephalogram wasnormal, and an electrocardiogram showed auricular fibrillation.Laboratory examinations revealed the following: red blood cell count490 X I04/mm3, hematocrit 45%, white blood cell count 18,600/mm3 (79.5%neutrophils with 50% rod form, 20% lymphocytes and 0.5% basophils), totalbilirubin 1.6 mg/100 ml, S-GOT 55 Karmen units, LDH 535 Wroblewski units,alkaline phosphatase 3.0 Bodansky units, total cholesteroI152mg/100ml, ureanitrogen 28mg/100ml, blood sugar 135mg/100ml, chloride 92meq/l, potas-sium 3.2meq/l, sodium 138meq/l, calcium 4.5meq/l, c-reactive protein 6-plus,Fig. 3. Immunoelectrophoretic analysis of serum. Arrows show abnormal pre-cipitation arcs formed with anti-sera. Anode is on the left. ANTI-WHS, anti-wholehuman serum; ANTI-IgG, anti-human IgG.1.040po100°280 20 tTUBE NUr~BERFig. 4. Elution pattern of Sephadex G-200 gel filtrations of serum. Fractionsbetween arrows were subjected to further analysis.z:ol-e::(0:I-z:W~ 0.5ouz:wI-o0:c...3Arima et al.: An extremely basic monoclonal IgG in an aged apoplectic patientProduced by The Berkeley Electronic Press, 1976212 T. ARIMA et aI.erythrocyte sedimentation rate 88 mmin the first one hour, anti-streptolysin-O-titer 160 Todd units, rheumatic factornegative and serological tests for syphi-lis negative. Urinalysis revealed pro-teinuria I-plus, minimal hematuria andBence-Jones protein negative. On cellu-lose acetate membrane electrophoresis,an abnormal band that migrated in thepost-gamma-region was found (Fig. 1).Total serum protein was 8.4gm/100mlwith 49.5% albumin, 4.2% al-globulin,14.5% a2-globulin, 9.7% p,-globulin,19.3% r-g1obulin and 2.3% abnormalglobulin.Quantitation of serum immunoglo-bulin indicated 1,700mg/l00ml IgG,222 mg/l 00 ml IgA and 108 mg/100 mlIgM. The abnormal globulin showednegative Sia water dilution test. OnFig.5A. Cellulose acetate membrane elec-trophoresis of fractions eluted from 5ephadexG-200 column. Numerials represent fractionson the column. Note that the abnormal pro-tein appears in the same fractions as 75 gam-ma-globulin. Anode is on the left.agar gel electrophoresis the abnormal globulin appeared in the post-gamma-region (Fig. 2). On immunoelectrophoresis precipitation arcs were present withanti-whole human serum and anti-IgG (Fig. 3). The protein was further iden-tified as an IgG with A-type light chain by immunoelectrophoresis. The bonemarrow aspirate was normal, containing 1% plasmacyte and 18% lympho-cytes. The patient became alert on the second hospital day but the hemiparesisremained. Treatment with urokinase, sulfopenicillin and glucocorticoids wasinstituted. On the 19th hospital day, cholecystitis was revealed.The patient became well after 10 weeks hospitalization except for the lefthemiparesis and the presence of abnormal gammaglobulin in the serum.Sephadex G-200 gel filtration of the serum was performed to determinethe molecular size of the abnormal protein (Fig. 4). Several fractions (:;23·-29)of the gel filtration were subjected to acetate membrane electrophoresis after4Acta Medica Okayama, Vol. 30 [1976], Iss. 3, Art. 6http://escholarship.lib.okayama-u.ac.jp/amo/vol30/iss3/6Extremely Basic IgG in Bacterial Infection 213lyophilization. As shown Fig. 5 and 6, the abnormal protein appeared in thesame fraction of 7S-gammaglobulin. All these analyses were performed ac-cording to the methods described previously (5).NORMAL27 28BFig.5B. Densitometric patterns of cellulose acetate membrane electrophoresis.DISCUSSIONAxelsson, Bachmann and Hallen (6) analysed sera by electrophoresis from6,995 persons above 25 years of age that revealed a M-component in 64 cases.M-component was more common at higher age levels. The concentration ofM-component was usually low and in only 10 sera did it exceed I gm/lOOml.From an immunological point of view, the distribution of M-component was61 % IgG. Plasma cell count in the bone marrow was less than 3% in 77% ofcases studied. A diagnosis of myelomatosis was strongly suggested in only 3cases.Many instances of benign monoclonal gammopathy were accompanied5Arima et al.: An extremely basic monoclonal IgG in an aged apoplectic patientProduced by The Berkeley Electronic Press, 1976214 T. ARIMA et aI.with infection, hematological abnotmality, polyneuropathy or myopathy (7).The case described in the present report was an old male patient withprolonged pneumonia and cholecystitis, and without clinical features of myelo-matosis. The patient could be diagnosed as benign monoclonal gammopathyor asymptomatic monoclonal gammopathy. The serum of this case containedan extremely basic IgG which could be used for studying the structural hetero-geneity of IgG.Acknowledgments. We wish to thank Dr. K. Kosaka for his guidance throughout thisstudy and Mrs. H. Ishii, Mrs. H. Tsuchida and Mr. Y. Ishii for their technical contributions.REFERENCES1. Eagle, R. L. and Wallis, L. A.: Immunoglobulinopathies. Charles C. Thomas, Inc., Spring-field, Illinois, pp 202-204, 1969.2. Hammack, W. j., Bolding, F. E. and Frommeyer, W. B.: Dysgammaglobulinemic syn-drome. Ann Intern. Med. SO, 288-299, 1959.3. Smith, E. W.: Non-myelomatous paraproteinemia. Clin. Res. Proc. 5, 158-159, 1957.4. Waldenstrom, J.: The occurence of benign, essential monoclonal (M-type), non-macro-molecular hyperglobulinemia and its differential diagnosis. IV. Studies in the gammo-pathies. Acta Med. Scand. 176, 345-365, 1964.5. Arima, T., Miyamoto-Sudo, C., Hirohata, M., Tsunajima, T., Tanigawa, T., Kuwauchi,S. and Imai, M.: Further studies on an eleventh case of heavy (H'Yl) chain disease-clinical studies. Acta Med. Okayama. 29, 199-208, 1975.6. Axelsson, D., Bachmann, R. and Hallen, J.: Frequency of pathological proteins (M-components) in 6,995 sera from an adult population. Acta Med. Scand. 179, 235-247, 1966.7. Zawadzki, Z. A. and Edwards, G. A.: Dysimmunoglobulinemia in the absence of clinicalfeatures of multiple myeloma and macroglobulinemia. Am. j. Med. 42, 67-88, 1967.6Acta Medica Okayama, Vol. 30 [1976], Iss. 3, Art. 6http://escholarship.lib.okayama-u.ac.jp/amo/vol30/iss3/6

An extremely basic monoclonal IgG in an aged apoplectic patient with prolonged bacterial infection

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An extremely basic monoclonal IgG in an aged apoplectic patient with prolonged bacterial infection

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