When evaluating the patient with a paraprotein it is important to rule out conditions that require treatment such as myeloma, amyloid and plasmacytoma. The patient did not have any end organ damage attributable to myeloma. However we were concerned that the patient may have amyloid due to her symptoms of heart failure, peripheral neuropathy and orthostatic hypotension.  Here is a useful table from Rosenzweig and Landau (http://www.jhoonline.org/content/pdf/1756-8722-4-47.pdf )

In order to rule out plasma cell myeloma a skeletal survey was performed which showed no lytic lesions. A bone marrow aspirate and trephine biopsy showed 6% plasma cells confirming a plasma cell neoplasm but not fulfilling the criteria for myeloma. In the absence of any lymphadenopathy or B symptoms lymphoma is unlikely. This would usually be classified as MGUS but as the patient has symptoms of amyloid it is important to rule this out.

Questions:

• How does amyloid occur?
• What testing can be done to look for presence of amyloid?
• How would you investigate for end organ damage?

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