Patient presented to clinic with mental fogginess and abnormal lab results. Here is the smear. Got the diagnosis? #meded 1/

Another hint. Total protein was 15. IgG level was >10 g/dL. A bone marrow biopsy reveled 80% plasmacytosis. #meded #mmsm #wmsm 2/

This patient presented with hyperviscosity syndrome (HVS) from heavy myeloma burden. Serum viscosity was 3.9. A few pearls on HVS. Most common with IgM (as in waldenstrom’s) because it is so large (925 kDa ca IgG 150 kDa) and 80% intravascular. #meded 3/

IgM >3, IgA>5, IgG>7 are rules of thumb for thinking about HVS. Viscosity is measured by the time required for a serum sample to flow through a tube under gravity. Values >4 typically track with HVS (confusion, stroke, tinnitus, vision changes, SOB/HF, bleeding) #meded #mmsm 4/

Treatment involves hydration, treating the underlying dz quickly, and usually plasma exchange. Each session of PLEX removes about 20-30% Ig. Blood transfusions should be held upfront if possible to avoid worsening hyperviscosity symptoms. #meded #mmsm 5/5 http://www.bloodjournal.org/content/119/10/2205?sso-checked=true

A follow up: received a call re same pt that sodium was low at 124. What do you do?
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I do what @TWhittier_RUSH taught me: get a sodium off a blood gas for suspected pseudohyponatremia from hyperproteinemia. Result: Na 134. Phew! #meded 6/