Triclonal Gammopathy in Multiple Myeloma with Bleeding Diathesis: A Case Report

Gammopathies have clinical and diagnostic significance for lymphoproliferative disorders and plasma cell dyscrasias such as multiple myeloma which is distinguished by the malignant growth of a plasma cell clone that generates monoclonal immunoglobulin. A 70-year old patient was evaluated for recurrent epistaxis and bleeding per rectum along with severe anemia in the past two months. A general physical examination revealed pallor. Blood tests showed pancytopenia.

Hemogram, biochemical investigations, SPE, Serum-free light chain assay, Immunofixation electrophoresis, Bone marrow aspiration cytology & Immunophenotyping, and flow cytometry.

Immunofixation electrophoresis showed triclonal gammopathy IgM Kappa, IgG Kappa, and IgA Lambda and SPE quantitation of M band-5.6 gm%. Serum kappa and lambda light chains were 204 mg/L and 11.22 mg/L respectively, and the kappa/lambda ratio-18.18. Bone marrow aspiration cytology showed extensive rouleaux formation of RBCs, scattered myeloid and erythroid cells, and a few abnormal plasmacytoid cells accounting for approximately 4% of all nucleated cells. The flow cytometry revealed clotted aspirate and the smear showed occasional scattered plasma cells. The bone marrow- immunophenotyping showed CD38/CD138 bright plasma cells (4.7%). The plasma cells showed co-expression of CD81, and CD27 and were dim for CD45 with variable CD56 expression. A severely altered A/G ratio was observed.

In plasma cell dyscrasias and lymphoproliferative diseases, monoclonal gammopathies are often observed, while the biclonal variety is less frequent. However, tri clonal gammopathy having a combination of IgM Kappa, IgG Kappa, and IgA Lambda is extremely rare and their clinical significance is unknown.