Misfolded

A 70 year old lady presents with generalised weakness and fatigability for 8 months. She had no other complaints, while her medical and surgical histories are unremarkable.

Her FBC is significant for a Hb of 5.4 g/dL, along with a low MCV, MCHC and MCH. Her electrolytes, liver functions, renal functions, and coagulation profiles are normal.

Repeated questioning reveals a history of intermittent tarry colored stools. Initial and repeat upper GI endoscopies are normal, as is a colonoscopy.

Select Relevant Investigations
Barium Follow-Through

Performed

You realize that a barium series may obscure any overt bleeding, and potentially interfere with subsequent investigations.
Capsule Endoscopy

Performed

There is active bleeding from the proximal jejunum; the mucosa in that region appears nodular, polypoid, and eroded. The remainder of the jejunum shows thickening of the valvulae conniventes.
Push Enteroscopy & Biopsy

Performed

Congo red staining of jejunal biopsies reveals extensive, dense, homogenous deposits in the lamina propria and submucosa, with apple-green birefringence with polarized light; the hematoxylin stain reveals amorphous, salmon-pink, sparsely cellular hyaline material.
Serum Protein Electrophoresis

Performed

Serum protein electrophoresis and immunofixation reveal a monoclonal band of IgG lambda paraprotein.

Select Relevant Management
Blood Transfusion
Chemotherapy
Dexamethasone
Jejunectomy