Pathways Case Studies: May 2020

39-year-old man who on a routine physical exam was found to have elevated serum creatine at 1.4 mg/dL associated with elevated serum free kappa to lambda ratio at 27. The serum protein electrophoresis (SPEP) test was negative for paraprotein. Urine protein electrophoresis (UPEP) showed a free kappa light chain. Bone marrow biopsy was done and showed 1-2% kappa restricted plasma cells. Additional workup revealed a 24-hour urine protein of 0.5 g, negative fat pad biopsy for amyloid, and negative skeletal survey. A kidney biopsy was performed.

	Sam Albadri, M.B., Ch.B., M.S. Fellow, Renal Pathology Mayo Clinic @sam_albadri
	Samih Nasr, M.D. Consultant, Anatomic Pathology Mayo Clinic Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine and Science

A 13 year old female with no prior medical history presented with worsening chronic right lower quadrant abdominal pain. CT imaging identified a complex 8 cm ovarian mass.

Serum tumor markers were: LDH 1671 U/L, HCG <2 IU/ml, AFP 3.2 ng/mL and CA-125 50 U/mL. The patient underwent right salpingo-oopherectomy.

	Farah Baban, M.B., Ch.B. Resident, Anatomic and Clinical Pathology Mayo Clinic @BabanFarah
	J. Kenneth Schoolmeester, M.D. Consultant, Anatomic Pathology Mayo Clinic Assistant Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine and Science

A mother and her 3 month old son present to their local physician for what the mother believes is decreased arm movement and pain when moving her son’s arms. Initial imaging of the boys arms revealed bilateral radial fractures and associated lytic bony lesions (Figure 1). Clinically child abuse was an initial concern. A follow up skeletal survery, along with an ophthalmology consult, was performed to assess for further child abuse related injuries. Skeletal survery revealed bilateral, medial tibial lytic lesions (Figure 2). Biopsy was performed of the right sided tibial lesion and showed a mixed lymphohistiocytic infiltrate with associated fibrosis (Figure 3).

	Casey Gleue, M.D. Resident, Anatomic and Clinical Pathology Mayo Clinic
	Jorge Torres-Mora, M.D. Consultant, Anatomic Pathology Mayo Clinic Assistant Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine and Science

19 year old G1P0 delivered a nonviable male fetus at 31 weeks. Placenta was grossly described as a 2,297g aggregate of disrupted placenta tissue with tan-pink spongy parenchyma admixed with numerous vesicles.

	Jodi Hilderbrand, M.S., PA(ASCP)CM Pathologists’ Assistant, Pathology Mayo Clinic Instructor in Laboratory Medicine and Pathology Mayo Clinic College of Medicine and Science
	Michael Henry, M.D. Consultant, Anatomic Pathology Mayo Clinic Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine and Science