Correspondence

HIV Infection Masquerading as Monoclonal Gammopathy of Undetermined Significance

N Engl J Med 2003; 349:1192-1193September 18, 2003

Article

To the Editor:

Various hematologic disorders, including plasma-cell dyscrasia,1 are increasingly being diagnosed in patients with human immunodeficiency virus (HIV) infection. Monoclonal gammopathy of undetermined significance (MGUS), generally considered to be a disease of the elderly, affects up to 3 percent of persons 50 years of age or older.2 Nevertheless, the presence of a monoclonal protein in HIV-positive persons is not a rare event.3 Since the standard care for MGUS is regular follow-up and monitoring for progression, patients in whom MGUS is the initial manifestation of HIV infection could miss out on the benefit of early antiretroviral therapy, should the underlying infection remain undiagnosed. A recent case illustrates that young patients with MGUS should undergo screening for HIV infection and receive care accordingly.

A 46-year-old man was found to have slightly elevated levels of serum globulins at a routine check-up. Serum protein electrophoresis and immunofixation showed that the level of monoclonal IgG kappa was 2840 mg per deciliter. A diagnosis of MGUS was made on the basis of the unremarkable findings on examination of a bone marrow biopsy specimen and the absence of lytic bone lesions, symptoms, and infections. During follow-up, the patient's serum IgG paraprotein level fluctuated between 1800 and 3400 mg per deciliter, and examination of two additional bone marrow biopsy specimens revealed no evidence of progression to myeloma or lymphoma. During this interval, the patient was in overall good health, except for two episodes of pneumococcal infection, both of which required hospitalization and resolved after treatment with antibiotics.

Four and a half years after the initial diagnosis of MGUS had been made, the patient was again hospitalized for pneumonia, complicated by acute renal failure. Pneumocystis carinii pneumonia and cytomegalovirus infection were subsequently diagnosed on the basis of the findings in bronchoalveolar-lavage specimens. Blood cultures were positive for Candida albicans. These unexplained opportunistic infections prompted testing for HIV infection. The patient was discovered to be positive for HIV type 1, with a viral load of 43,000 copies per milliliter and a CD4 cell count of 9 per cubic millimeter. A diagnosis of advanced acquired immunodeficiency syndrome was made. The patient's condition deteriorated rapidly, and he died two months later.

In retrospect, had HIV infection been suspected and had the patient been tested for it after the initial diagnosis of MGUS, he would have received highly active antiretroviral therapy. We therefore recommend that young patients with MGUS, in addition to those with multiple myeloma,4 undergo testing for HIV infection if there is a possible history of exposure to this virus.

Chuanyi M. Lu, M.D.
Bruce J. Dezube, M.D.
Liron Pantanowitz, M.D.
Beth Israel Deaconess Medical Center, Boston, MA 02215
lpantano@bidmc.harvard.edu

4 References

1. 1

   Yee TT, Murphy K, Johnson M, et al. Multiple myeloma and human immunodeficiency virus-1 (HIV-1) infection. Am J Hematol 2001;66:123-125
   CrossRef | Web of Science | Medline

2. 2

   Kyle RA, Therneau TM, Rajkumar SV, et al. A long-term study of progression in monoclonal gammopathy of undetermined significance. N Engl J Med 2002;346:564-569
   Full Text | Web of Science | Medline

3. 3

   Fiorino AS, Atac B. Paraproteinemia, plasmacytoma, myeloma and HIV infection. Leukemia 1997;11:2150-2156
   CrossRef | Web of Science | Medline

4. 4

   Pouli A, Lemessiou H, Rontogianni D, et al. Multiple myeloma as the first manifestation of acquired immunodeficiency syndrome: a case report and review of the literature. Ann Hematol 2001;80:557-560
   CrossRef | Web of Science | Medline

Citing Articles (3)

Citing Articles

1. 1

   M. J. Molina-Garrido, C. Guillén-Ponce, A. Mora, M. Guirado-Risueño, M. A. Molina, M. J. Molina, A. Carrato. (2007) Deposition-associated diseases related with a monoclonal compound. Clinical and Translational Oncology 9:12, 777-783
   CrossRef

2. 2

   Lynda Anne Szczech, Albert Anderson, Christian Ramers, John Engeman, Matthew Ellis, David Butterly, David N. Howell. (2006) The Uncertain Significance of Anti–Glomerular Basement Membrane Antibody Among HIV-Infected Persons With Kidney Disease. American Journal of Kidney Diseases 48:4, e55-e59
   CrossRef

3. 3

   (2003) HIV Infection Masquerading as Monoclonal Gammopathy of Unknown Significance. New England Journal of Medicine 349:24, 2362-2363
   Full Text

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