From the Guidelines
The 78-year-old man's laboratory results show hypoglobulinemia (low globulin level of 1.7 g/dL) with a slightly low total protein (5.5 g/dL) but normal albumin (3.9 g/dL), and he should be referred to a hematologist for evaluation of possible immunodeficiency or an underlying condition affecting immunoglobulin production, as recommended by the most recent guidelines 1.
Evaluation and Testing
Further testing should include:
- Serum protein electrophoresis (SPEP) to identify and quantify the M-protein (IgM) 1
- Immunoglobulin levels (IgG, IgA, IgM) to characterize the specific deficiency
- Possibly immunofixation to further characterize the specific deficiency
- Bone marrow aspirate and biopsy to document clonal lymphoplasmacytic cell population and confirmed by immunohistochemistry and/or flow cytometry 1
- Testing for MYD88 (L265P) mutation, which is a commonly recurring mutation in patients with Waldenström macroglobulinemia (WM) 1
Monitoring and Management
While awaiting specialist evaluation, the patient should be monitored for increased susceptibility to infections, particularly respiratory and sinus infections. No specific medication is indicated until the underlying cause is determined. The low globulin level suggests decreased production of immunoglobulins, which could be due to various conditions including common variable immunodeficiency, medication effects, protein-losing enteropathy, or early stages of certain hematologic disorders. The normal albumin indicates that liver synthetic function is likely preserved. The patient's age increases the likelihood of an acquired rather than congenital immunodeficiency, possibly related to aging of the immune system or an underlying malignancy.
Prognosis and Outcome
The prognosis and outcome of this patient will depend on the underlying cause of the hypoglobulinemia and the presence of any other underlying conditions. The International Prognostic Scoring System for WM (IPSSWM) may be useful for prognostication of WM at first-line treatment initiation 1. However, the patient's management and treatment will depend on the results of the evaluation and testing, and the hematologist's recommendation.
From the Research
Laboratory Results
- The patient's CBC and CMP are normal, except for the following:
- Total protein: 5.5
- Albumin: 3.9
- Globulin: 1.7
Albumin and Globulin Levels
- The albumin level is slightly below the normal range, which can be associated with various conditions, including liver disease, inflammation, and kidney dysfunction 2, 3, 4.
- The globulin level is within the normal range, but the albumin-to-globulin (A/G) ratio may be useful in evaluating the patient's condition 2.
- A study found that a low-normal albumin level is associated with a high risk of cardiovascular disease and mortality in the general population, and even a slight decrease in serum albumin level can be associated with the rapid progression of kidney dysfunction 4.
Inflammation and Serum Protein Levels
- Serum protein electrophoresis can be used to identify patients with multiple myeloma and other serum protein disorders, and to differentiate between monoclonal and polyclonal gammopathies 5.
- A negative correlation between albumin and C-reactive protein (CRP) levels has been found, indicating that inflammation can affect serum protein levels 3.
- A study found that hypoalbuminemia with or without a polyclonal gammopathy can cause a low anion gap, which may be relevant to the patient's condition 6.
Potential Conditions
- The patient's laboratory results and medical history should be evaluated to determine the underlying cause of the low albumin level and the potential presence of kidney dysfunction or other conditions 2, 3, 4.
- Further testing, such as serum protein electrophoresis, may be necessary to rule out multiple myeloma or other serum protein disorders 5.