PMC4360848_01
Serial changes in the hemoglobin, hematocrit, serum creatinine (sCr), serum levels of albumin (sAlb), calcium (Ca), and phosphorus (Pi) during the observation period. The level of sCa increased up to 11.7 mg/dL in August 2012 despite combined management with hemodialysis using a low-calcium dialysate. Thereafter, the patient received occasional red blood cell (RBC) transfusions for anemia.
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Nevertheless, the range of motion in his shoulders, elbows, and hips remarkably decreased in the beginning of August 2012, at which time the serum calcium level further increased up to 11.7 mg/dL, despite combined management with HD using a low- calcium dialysate (Fig. 1).
Musculoskeletal findings. The shoulder masses, which appeared similar to shoulder pads worn by American football players, were firm and immobile. The masses were more prominent on the right than on the left (A). A similar trend was noted in the upper torso muscles, with a presumable pseudoathletic appearance (B). Technetium-99m (99mTc)-pyrophosphate scanning failed to show any remarkable uptake in the corresponding portions of the markedly enlarged shoulders (C).
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August 2012 (Fig. 2A and B). Arthrograms revealed no skeletal deformities within the joints, while technetium-99m (99mTc)-pyrophosphate scanning showed a marginal uptake in the corresponding joints, including the shoulder, elbows, hips, knees, and ankles (Fig. 2C).
Electrophoretic pattern of serum proteins (A) and immunoelectrophoresis of the urine (B). Despite the absence of a distinct spike in the electropherogram of serum proteins, abnormal precipitation arcs against anti-IgG and anti-kappa antibodies were clearly confirmed (black arrows) on urine immunoelectrophoresis. Another M-bow against the anti-kappa antibody was also noted, indicating the concomitant presence of Bence Jones proteins (white arrow).. Abbreviation: Alb, albumin.
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IgG kappa (kappa) monoclonal component and Bence Jones proteins (kappa type), despite the absence of a distinct serum electrophoretic spike (Fig. 3). In addition, a bone marrow biopsy performed in the middle of September 2012 revealed 50% plasma cells with kappa light chain restriction.