On the day she was seen by her general practitioner she was weak and hypotensive (90/58 mm Hg). was seen by her general practitioner she was weak and hypotensive (90/58 mm Hg). Examination showed Anisodamine an underweight woman (body mass index 19) with a blood pressure of 90/60 mm Hg, pulse 90 beats per minute, muscle wasting, no oedema, and no focal neurological signs. Results of initial laboratory investigations were sodium 128 mmol/l, potassium 5.2 mmol/l, urea 7.2 mmol/l, creatinine 105 mol/l, total protein 52 g/l, albumin 27 g/l, aspartate transaminase 68 IU/l, alanine transaminase 86 IU/l. Serum immunoglobulins IgG, IgA, and IgM were within the reference range. A short synacthen test produced blood cortisol concentrations of 254 mmol/l at 0 minutes and 316 mmol/l at 30 minutes. She was given alternative steroids and began to improve. Investigation of her low serum albumin showed proteinuria (total protein excretion 8.2 g/24 hours). Serum electrophoresis showed no visible paraprotein band, and a subsequent immunofixation was unfavorable. Urine electrophoresis showed a dense albumin band and one additional band, typed by immunofixation as kappa light chains (600 mg/l). She was referred for nephrology assessment. Serum amyloid component P (SAP) scintigraphy showed heavy amyloid load in spleen and liver. In view of these findings a renal biopsy was not performed, and she was diagnosed as having primary amyloidosis (AL amyloidosis). She was treated with melphalan and dexamethasone. Summary points The presence of a serum paraprotein band is not diagnostic of myeloma Monoclonal gammopathy of unknown significance (MGUS) is usually a common explanation for low concentration paraprotein bands and requires follow-up Urine Anisodamine and serum electrophoresis should be performed for suspected plasma cell dyscrasia Paraprotein bands can be associated with other non-myeloma disease, including amyloid lymphoma, leukaemia, contamination, and chronic inflammatory disease Absence of paraprotein bands does not include plasma and dyscrasia Case 2 A 72 year old woman was referred to her local haematology outpatient clinic for investigation of a normocytic anaemia (haemoglobin 98 g/l) with normal blood film, identified from a full blood count requested when she attended her general practitioner with a recent chest contamination. When seen, she was clinically anaemic, appeared otherwise in good health, and reported no specific symptoms. Two episodes of upper productive respiratory tract contamination in the previous three months had both responded IL24 to antibiotics. Laboratory investigations showed an anaemia of 101 g/l, neutrophil count of 1 1.9109/l and platelet count of 110109/l, plasma viscosity of 2.25, and serum calcium (corrected) 2.83 mmol/l. Renal function was unremarkable Anisodamine for age (serum urea 6.8 mmol/l, creatinine 98 mol/l), and urine was negative on dipstick testing. Serum total protein was 78 g/l, albumin was 38 g/l, serum IgG was 36 g/l, and both IgA and IgM were suppressed ( 0.2 g/l). Serum protein electrophoresis showed a paraprotein band, typed by immunofixation as IgG kappa and assessed by densitometry to become 33 g/l. Urine electrophoresis demonstrated no monoclonal music group. What follow-up is necessary once an individual has been discovered to truly have a paraprotein music group? 3-6 month electrophoresis for IgG Primarily, IgA, or IgM rings of significantly less than 15 g/l in Anisodamine individuals without indicators Annual electrophoresis thereafter for steady IgG, IgA, or IgM rings of significantly less than 15 g/l, where there are no associated indicators to get a plasma cell dyscrasia Recommendation to a haematologist Anisodamine for IgA or IgG rings 15 g/l or IgG, IgA, or IgM rings 15 g/l with associated indicators to get a plasma cell dyscrasia and additional Ig rings (IgE and IgD are uncommon) Immediate testing after initial recognition of the monoclonal music group: full bloodstream count, calcium mineral, and renal function Magnetic resonance imaging demonstrated diffuse bony lesions.