Studies in the older literature indicated that there was little chance of progression to malignant diseases such as multiple myeloma, Waldenstrom's macroglobulinemia, chronic lymphocytic leukemia, non-Hodgkin's lymphoma, AL amyloidosis etc. More recent studies by Kyle at the Mayo Clinic, where he has carefully followed cases for many years, have indicated that 19% of cases of MGUS developed a malignant paraproteinemia within 10 years. An additional 39% of the group died from unrelated causes during the 10 year follow-up. Bence-Jones proteins are uncommon in MGUS being found in only a few percent of cases. The presence of Bence-Jones protein or increasing levels of serum protein requires careful surveillance of the patient.Present recommendations are that cases of MGUS be monitored with periodic electrophoresis, at first repeated in 4-6 weeks to see if paraprotein levels are increasing, and approximately every 6 months if levels are constant or decreasing. The presence of any discrete bone lesions, anemia, neuropathy or renal compromise requires more extensive evaluation. A bone marrow biopsy should be performed at the time of initial evaluation and repeated at a later stage, if needed. Additional information may be obtained by measuring serum beta-2-microglobulin levels and by immunohistochemical studies of bone marrow and peripheral blood lymphocytes. Patients with MGUS should not be given chemotherapy unless they develop malignant disease

■■■Hypogammaglobulinemia

This serum was obtained from an adult who had experienced several severe infections during the preceding year. He had not had any unusual infections prior to this time. The gamma region is low at 0.2g/dl and all three immunoglobulins are well below normal limits. IgG subclasses showed low levels of IgG1, IgG2 and IgG3. This supports a diagnosis of common variable immunodeficiency

■■■Agammaglobulinemia

Infantile X-linked agammaglobulinemia or Bruton's disease is a genetic defect that prevents the production of almost all immunoglobulins. Typically the patients have low levels of IgG, less than 150 mg/dl, and undetectable amounts of the other immunoglobulins. Without replacement therapy affected individuals suffer repeated severe bacterial infections including pneumonias, meningitis and osteomyelitis. Pneumocystis carinii pneumonia and viral infections like cytomegalovirus also occur. At present the patients are managed by infusions of intravenous gamma globulins and early use of antibiotic therapy. The availability of i.v. gamma globulin has greatly decreased the morbidity from when intramuscular gamma globulin was the only available choice

It is only practical to replace IgG, since it has a half life of about 23 days in the circulation. IgA and IgM have half lives of 5.8 and 5.1 days respectively, making replacement impractical. Many individuals with IgA deficiencies experience anaphylactic reactions to immunoglobulin or plasma preparations due to the presence of class or allotype specific antibodies against IgA. It is important to use an IgA free preparation for these individuals. The currently available preparations of intravenous gamma globulin are controlled to guarantee that significant antibody titers against an extensive list of common organisms are present in each lot, unlike the older intramuscular preparations which were not as standardized

■■■Dysgammaglobuniema

As can be seen in this pattern, dysgammaglobulinemias are not always apparent from serum protein electrophoresis. This serum was obtained from a teenage boy who had immunoglobulin deficiency with hyper-IgM, which is sometimes seen as a variant of infantile X-linked agammaglobulinemia. In this case there was no family history of repeated or extensive infection or early childhood death. The maternal uncles were healthy. The presence of significant IgA also suggests that this individual's disease is not genetic agammaglobulinemia. This patient has been followed for 8 years on gamma globulin therapy with no evidence that the immune deficiency is transient. The IgM is polyclonal and the patient produces IgM antibodies to antigenic stimulation

■■■Bisalbuminemia

 These patterns show an uncommon genetic condition in which two variants of albumin are synthesized. One is the normal sequence and the otherhas at least one amino acid residue different. There are at least 13 types recognized. On the gel two albumin bands are visible, the faster one showing up as a shoulder on the main peak in the scan. The urine shows the same albumin pattern. Two other genetic variants of albumin synthesis include a form that readily forms dimers, giving a broad albumin peak,and andanalbuminea, the absence of serum albumin. This patient also has hepatic cirrhosis, which will be discussed later

■■■Alfa1antitrypsin deficiency 

This pattern was found among routine orders for serum protein electrophoresis. There was no alpha-1-antitrypsin band visible on the gel. Alpha-1-antitrypsin was not detectable immunochemically. There are 5 common alleles of AAT and over 25 rare forms. Although some have atypical mobility in standard high resolution protein electrophoresis, many require special techniques like acid starch gel electrophoresis for detection. The very low and absent phenotypes Pi null and Pi Z are associated with development of neonatal cryptogenic hepatitis or childhood cirrhosis in 5-20% of affected individuals. Pi Z phenotype individuals are at high risk to develop a basilar emphysema in adulthood. Occasionally adult onset liver disease appears, but usually careful review finds a history of neonatal jaundice. The development of emphysema is greatly aggravated by smoking and high degrees of air pollution

The normal mean level for AAT is 135mg/dl. The Pi Z phenotype usually has levels of 10-20% of normal and is found in about 1 in 1500 northern European caucasians. The Pi or null phenotype is rare. Individuals with levels below 40% of normal are at increased risk of disease

Other types of neonatal hepatitis and idiopathic respiratory distress syndrome of infancy may show low levels of AAT because of consumption. Phenotyping and family studies can readily distinguish these from genetic deficiencies

■■■Antitrypsin deficiency with cirrhosis

This serum was obtained from an adult who was admitted to the hospital with severe cirrhosis, which had progressed to ascites. The patient gave a history of long standing cirrhosis and did not consume alcohol. He was a moderate cigarette smoker and evaluation showed a mild emphysema. Other medical history included a previous splenectomy for pancytopenia. The AAT was Pi Z type

The electrophoretic pattern shows a low serum albumin, due to loss to ascites and decreased production due to liver destruction. The alpha-1 band is absent. There is a massive polyclonal gammopathy with total fusion of the beta and gamma regions. Both IgG and IgA are significantly elevated

■■■Inflammation

Increases in the acute phase reactive proteins are seen as a response to inflammation. The traditional characterization of patterns as acute, subacute and chronic is of limited value to the clinician, and is not always accurate. This pattern shows an increase in alpha-1-antitrypsin, haptoglobin and C3 complement, as well as some polyclonal elevation of gamma globulins.

Following surgery C reactive protein increases in 6-8 hours reaching a maximum at 48-72 hours, followed closely by alpha-1- acid glycoprotein Alpha-1-antitrypsin, haptoglobin and fibrinogen levels increase at 24 hours. In the next few days prealbumin, albumin, alpha-lipoprotein and transferrin may decrease, because of decreased nutrition. C3 complement and ceruloplasmin may increase during the subacute phase

In myocardial infarction C-reactive protein, alpha-1-acid glycoprotein, alpha-1-antitrypsin, haptoglobin and fibrinogen rapidly increase, peaking at about 5 days and returning to normal in about a month. The nutritionally sensitive proteins and IgG reach minimum levels in 5 days and return to normal. Ceruloplasmin and C3 reach a maximum during the second week

In infectious disease of bacterial origin alpha-1-acid glycoprotein, alpha-1-antitrypsin, haptoglobin and C-reactive protein may reach very high levels. In most viral diseases there is much less increase in C-reactive protein and alpha-1-acid glycoprotein. The convalescent phase of infectious diseases may be accompanied by a rise in immunoglobulins. This is most marked in hepatitis

■■■Rheumatoid Disease

Severe polyarticular rheumatoid arthritis and systemic lupus erythematosus may show a variety of electrophoretic changes. This pattern illustrates a moderate polyclonal gammopathy with elevation of IgA and IgG. This may be more marked in severe SLE. Acute phase reactants are of some value in assessing the activity of the disease, especially elevations of haptoglobin and both increases and decreases of C3

 The C3 peak may decline or disappear in cases with large scale immune complex deposition, especially in SLE with severe renal involvement. Alpha-1- antitrypsin does not change as much as in infectious disease Immune complex patterns (see page 8) may be seen during periods of disease activity. Serial measurements of total hemolytic complement, C3, C4 and B can be of use in following the disease activity of selected patients

■■■Systemic Sclerosis

This pattern is typical of severe rheumatoid disease in the active phase. The alpha-2 globulin and beta globulins are elevated reflecting acute and subacute inflammation. There is some polyclonal elevation of gamma, with an irregular banding pattern caused by the presence of immune complexes. The alpha-2 band is much broader than normal

■■■Biliary Tract Obstraction

This pattern was observed from a plasma sample obtained from a 31 month old female with choledocal cysts causing bile duct obstruction. A prominent fibrinogen peak is present in the gamma. The specimen was bright yellow from the elevated bilirubin. The sharp peak in the beta region is the greatly increased beta-lipoprotein. This is reflected in the extremely high serum cholesterol and directly measured low density lipoprotein. The triglyceride level was normal. Liver enzymes including alkaline phosphatase, SGOT and amylase were all elevated. The alpha-2 region shows an increase in both major components. This patient had no evidence of renal disease

This specimen was obtained from a patient with a severe case of hepatitis A, who developed serious complications including bacterial meningitis and liver failure. Viral hepatitis causes a very potent stimulation of the immune response, even in patients with partial acquired immune deficiency from malignant hematopoietic disease. In the early stages of the disease, there is a significant increase in specific and total IgM. The IgM antibodies decrease over the course of the disease. This patient still has a relatively high IgM. An IgG response follows the IgM, very high levels may be reached as in this case. Much of the IgG is not specific for the infectious organism and the response is polyclonal as is shown by the broad gamma peak and kappa-lambda ratio of 1.8. In the later stages of disease a significant IgA response is usually observed

The irregular appearance of the gamma zone in this serum is due to the presence of large amounts of immune complexes. Although C3 complement and B are still normal, the C4 is significantly depressed because of the high rate of consumption. The albumin is low and some of the acute phase proteins are lower than expected because of the large amount of liver damage

■■■Severe Alcoholism

 Many chronic alcoholics develop severe liver disease. The earliest and still reversible phase is the deposition of fat in the hepatocytes. About 30% of heavy drinkers develop alcoholic hepatitis, characterized by random necrosis of hepatocytes, inflammation and hyaline changes. Protracted hepatitis leads to cirrhosis in many cases. Alcoholic cirrhosis starts out as a micronodular pattern, where fibrous bands bridge the nodules and regenerative areas are seen. In the end stages the liver may appear grossly macronodular and consist primarily of fibrous tissue

This patient was a severe alcoholic who did not show any signs of cirrhosis. He had received medical care for a number of moderate infections and had in the past shown some elevations of liver enzymes and bilirubin consistent with alcoholic hepatitis. At the time this specimen was obtained the patient had normal serum chemistries and no significant medical complaints. The only abnormality visible is a polyclonal increase in gamma. Unlike many alcoholics, this patient shows good nutritional status, reflected in the 4.4 g/dl albumin. The sample was collected in August and the high total protein reflects the short-term dehydration from the hot summer day

■■■Hepatic Cirrhosis, early

This pattern shows the relatively early stages of hepatic cirrhosis There is an increase in the acute phase reacting proteins in the alpha-1 and beta. The only other visible abnormality is the bridging between the beta and gamma zones. This reflects_the_production of IgM or IgA at increased rates. In cirrhosis IgA levels are usually high. Serum chemistries showed a moderate liver disease consistent with alcoholism

■■■Hepatic Cirrhosis, advanced

This pattern is typical of advanced alcoholic cirrhosis The albumin and many of the proteins in the alpha and beta regions are present in subnormal levels, because of decreased synthesis, due to the large amount of liver damage. The beta region is totally fused with the gamma region and the serum IgA level is high. There is a massive polyclonal increase in IgG

The polyclonal gammopathy in cirrhosis is thought to result from a combination of immunoregulatory abnormalities, reticuloendothelial damage and shunting of antigens into the systemic circulation, where they are processed in lymph nodes leading to a more vigorous response

■■■Cirrhosis with Ascites

These are the serum and urine patterns from an alcoholic patient with end stage cirrhosis admitted to the hospital with ascites. The serum pattern is even more extreme than the previous figure, having a lower albumin and higher polyclonal gammopathy. The urine pattern shows that the extremely low albumin level is not due to loss through the kidneys, but is the result of not being synthesized. Most of the urine protein is in the gamma region. Immunoelectrophoretic studies showed the presence of significant amounts of both kappa and lambda chains, and of fragments of immunoglobulin. The large excretion of protein reflects overflow and hypercatabolism of the immunoglobulin

 Bone marrow biopsies on similar patients have shown an extreme degree of plasmacytosis, as much as 45% of marrow white cells. If a severe alcoholic patient is suspected of having a monoclonal gammopathy, it is essential to perform complete immunohistochemical studies on the marrow. Typical severe

cirrhosis patients will show plasma cells positive for both gamma and alpha chains, and the kappa-lambda staining ratio will be between 1 and 2

■■■Liver Failure, juvenile

 A 1.5 year old boy was admitted to the hospital with liver failure. An extensive work-up did not reveal no the cause. The pattern shown here has a very low serum albumin and is otherwise normal. Immunoglobulins are normal for age. Urine protein excretion was normal

■■■Protein Loss, GI or Vascular

This pattern with a relatively low total protein and decreases in all fractions including alpha-2 is typical of protein loss through the gastrointestinal system or vascular loss. In this case the immunoglobulin levels are also decreased to subnormal levels. In renal protein loss the very large proteins alpha-2-macroglobulin and IgM are usually normal increased. Severe protein losing syndromes may also present clinically as acquired immune deficiency

■■■Short Bowel Syndrome

This pattern was obtained from the serum of a patient with the short bowel syndrome and consequent severe malabsorption. The very low albumin reflects the poor nutritional state. Immunoglobulins are normal as are the alpha globulins. lipoprotein peak is decreased. A prominent fibrinogen peak is seen in the gamma region, consistent with the clotting defect observed

■■■Nephrotic Syndrome

This pattern illustrates the nephrotic syndrome occurring in a severe alcoholic patient. The albumin is low and there is an elevation of the alpha-2 peak, specifically alpha-2-macroglobulin. There is also a prominent beta-2-lipoprotein peak. These findings are typical of nephrotic syndrome. There is a significant amount of beta-gamma bridging and a very high serum IgA, typical of post-necrotic cirrhosis. Immunoelectrophoresis did not show the presence of paraprotein. Urine protein was 12g/day

■■■Nephrotic Syndrome with Inflammation

This pattern shows a decreased total protein with decreased serum albumin and gamma. The alpha-1 peak is increased and the alpha-2 peak is slightly increased, primarily in the alpha-2- macroglobulin

 Immunoglobulin G was slightly decreased. Blood counts were

consistent with infection. Qualitative urine protein

+was 4

■■■Nephrotic Syndrome with Renal Failure

This serum was obtained from a patient who had a long history of nephrotic syndrome, which had progressed to renal failure. The total protein, albumin and gamma globulins are all significantly decreased. The alpha-2 macroglobulin and beta- lipoprotein are increased. The alpha-1 shows an absolute increase and some of the beta globulins show relative increases, because of acute phase responses probably due to the uremia

■■■Nephrotic Syndrome with Immune Deficiency

These two patterns both illustrate nephrotic syndrome with functional hypogammaglobulinemia. Both sera have relative elevations of alpha-2-macroglobulin, and extreme elevations of beta-lipoprotein as shown by the serum cholesterol. All other fractions are significantly decreased. The IgG levels are insufficient to be protective. Because of their larger size there is less loss of IgA and little, if any loss of IgM. nephrotic syndrome it is rare for molecules larger than 200,000 molecular weight to pass through the kidney. The increased beta- lipoprotein reflects a greatly increased risk of atherosclerotic heart disease

■■■Renal Failure with Pneumonia

Patients with nephrotic type renal failure have an increased susceptibility to severe infection. This specimen was obtained when a patient with renal failure was hospitalized with severe bacterial pneumonia. The total protein is low with relative elevations of alpha-1, alpha-2 and beta-lipoproteins. The gamma region shows a significantly higher level than the two patients sera on the previous page. A clear banding pattern is visible in the gamma corresponding to immune complexes and/or a restricted immune response

■■■Banding Pattern

 This pattern was obtained from the serum of a 27 year old male admitted to the critical care unit for treatment of an overdose of alcohol and doxepin. There is a large increase in the gamma region and a very large increase in IgG, without increased IgA or IgM. A clear banding pattern was visible on top of the polyclonal increase in gamma. Three of the bands were identified as IgG-kappa by immunofixation electrophoresis, including the small band following the beta-gamma division mark. These results are suggestive of an occult hematologic malignancy or possibly an autoimmune disease

Further laboratory results included a negative hepatitis panel, negative toxoplasmosis and cytomegalovirus, positive RPR and FTA-ABS for syphilis and positive human immunodeficiency virus by ELISA and western blot. Polyclonal and oligoclonal gammopathies are not unusual in HIV infections

■■■HIV related complex and Uremia

Human immunodeficiency virus infections cause a large variety of abnormalities

This individual has HIV related complex, which has not yet developed into acquired immune deficiency syndrome. The patient has severe uremia and nephrosis, losing 28 grams of protein per day. The serum protein is low and the albumin extremely low. Bridging of the beta and gamma regions is present. The beta- lipoprotein peak is prominent, but the alpha fractions are normal The urine reflects the serum pattern with the exception of alpha-2-macroglobulin and beta-lipoprotein, which do not pass through the kidney. The abnormalities observed are the result of renal disease in this case