FOCUS SAS Training Day

Leeds
Dr. Joanna Sheldon
Protein Reference Unit, St. George’s

1
Questions and Cases
1 List five disorders that are associated with the
presence of monoclonal immunoglobulins?

2 What is the electrophoretic mobility of

haemoglobin and fibrinogen on agarose pH 8.6
or comparable CZE?
3 What are the two major sites of production of the
plasma proteins?

4 What are the half-lives of IgG, IgA and IgM.

What is special about IgG?

5 What results need urgent action?

6 Which antibody is the most important and why?

7 What is the approx. % of BJP myeloma?

8 Where are the genes controlling immunoglobulin

production, what is the order or rearrangement
and what is the order of heavy chains?

9 What concentrations of fibrinogen and alpha-1

antitrypsin can be seen in inflammation?

10 What factors determine the concentration of an

analyte?

11 List the main proteins in each zone on the

2
 electrophoresis.

12 Which EP patterns should you immunofix?

13 What is di-thio-threitol and why do we use it?

14 What are the main proteins seen in a glomerular

proteinuria?

15 Where can paraproteins or BJP appear on the

serum or urine protein electrophoresis?
16 What are the possible reasons for finding
monoclonal light chain only on serum
immunofixation?

17 What are the possible reasons for finding heavy

chain only on serum immunofixation?

18 What electrophoresis pattern would you expect in

acute inflammation?

19 Are measurements of IgG, IgA and IgM traceable

and if they are, what to?

20 Which is the most common antibody deficiency?

3
Write interpretative comments for the following CZE separations from adult patients.
Some also show the serum immunofixations.
21. TP = 93g/L, IgG = 38.0 IgA =
0.7 IgM =1.6

22. IgG = 4.9 IgA = 0.9 IgM =0.5

23. IgG = 21.4 IgA = 6.9 IgM =2.5

24. IgG = 21.3 IgA = 3.1 IgM =0.5

4
25. IgG = 8.0 IgA = 0.8 IgM =0.5

26. IgG = 9.5 IgA = 6.3 IgM =1.9

27. IgG = 17.6 IgA = 2.6 IgM =0.8

28. Total protein = 111g/L (60-80)

IgG = 72.5g/L (6-16)
IgA = 1.0g/L (0.8-4)
IgM = 9.8g/L (0.5-2.0)

5
29. 44 year old woman complaining of tiredness
IgG = 8.0, IgA = 0.8 IgM =0.5 Urine total protein 0.4g/L

Your comments and actions

6
30. The patient is a 54 year old man. Pulmonary oedema, AKI
Immunoglobulin G 7.0 g/l ( 6.0 to 16.0 ) Auth
Immunoglobulin A 3.8 g/L ( 0.8 to 4.0 ) Auth
Immunoglobulin M 0.1 g/l ( 0.5 to 2.0 ) Auth

Your comments and actions

7
31. The patient is a 49 year old woman post PBSCT.
Total Protein 78 g/L ( 60 to 80 ) Auth
Immunoglobulin G 14.3 g/l ( 6.0 to 16.0 ) Auth
Immunoglobulin A 3.5 g/L ( 0.8 to 4.0 ) Auth
Immunoglobulin M 1.7 g/l ( 0.5 to 2.0 ) Auth

Your comments and actions

8
32. 72 year old female, known myeloma on treatment.

35g/L IgA lambda paraprotein. No obvious paraprotein detected

Small IgG kappa paraprotein (seen
since previous November)

What are the possible causes of these patterns and the changes if pattern and what
actions will you take?

9
33. 68 year old man – stroke investigation
Total Protein 68 g/L ( 60 to 80 ) Auth
Immunoglobulin G 11.3 g/l ( 6.0 to 16.0 ) Auth
Immunoglobulin A 2.2 g/L ( 0.8 to 4.0 ) Auth
Immunoglobulin M 0.6 g/l ( 0.5 to 2.0 ) Auth

CZE and
immunoglobulins
double checked from
primary tube

Serum Agarose gel

Serum protein electrophoresis
immunofixation electrophoresis
on CZE 72 hours later

Your comments

10
34. Look at the results below for a patient with an IgG paraprotein. The graph shows
the concentration of paraprotein for each serum sample received. Indicate at which
points you would have contacted the requesting clinician and why.

Your comments

11
35. 75 year old man - ? myeloma
Total Protein 72 g/L ( 60 to 80 ) Auth
Immunoglobulin G 7.5 g/l ( 6.0 to 16.0 ) Auth
Immunoglobulin A 0.9 g/L ( 0.8 to 4.0 ) Auth
Immunoglobulin M 0.4 g/l ( 0.5 to 2.0 ) Auth
Paraprotein 4g/L

Your comments and actions. What is the technique shown on the right and how does it
work?

12
36. 41 year old woman in neurology being investigated for back pain.
Total Protein 92 g/L ( 60 to 80 ) Auth
Immunoglobulin G 37.5 g/l ( 6.0 to 16.0 ) Auth
Immunoglobulin A 0.2 g/L ( 0.8 to 4.0 ) Auth
Immunoglobulin M 0.2 g/l ( 0.5 to 2.0 ) Auth
Paraprotein 24g/L
Urine total protein = 1.1g/L

Serum immunofixation Urine immunofixation

Your comments and actions

13
37. 83 year old man with proteinuria (0.4g/L) and slight polyclonally raised IgG and
IgA in the serum

Your comments and actions

14
15
38. 54 year old female with a rash – complex medical and social history.
Total Protein 92 g/L ( 60 to 80 ) Auth
Immunoglobulin G 39.1 g/l ( 6.0 to 16.0 ) Auth
Immunoglobulin A 1.1 g/L ( 0.8 to 4.0 ) Auth
Immunoglobulin M 0.1 g/l ( 0.5 to 2.0 ) Auth

Your comments and actions

Paraprotein 21g/L

16
17
39. 37 year old man with spleonmegaly
Immunoglobulin G 11.5 g/l ( 6.0 to 16.0) Auth
Immunoglobulin A 0.7 g/L ( 0.8 to 4.0) Auth
Immunoglobulin M 13.3 g/l ( 0.5 to 2.0) Auth
IgM kappa paraprotein 6g/L.

Your comments and actions

18
19