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Altered mental status and low anion gap in a patient with sickle cell anemia: a case report

Siddharth A Wartak*, Reshma A Mehendale, Benjamin Freda, Ashish Verma and David N Rose

Journal of Medical Case Reports 2012, 6:72  doi:10.1186/1752-1947-6-72

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Rouleaux and blusih tinge in the background on the blood smear in myeloma patients

Thein H Oo   (2014-07-30 00:24)  University of Texas MD Anderson Cancer Center email

To the Editor: I read this case report with interest and I would like to give some comments on this case.

The author did not mention the presence or absence of rouleaux (stacking up of red blood cells) in the peripheral blood smear of this patient. With very high monoclonal immunoglobulin level reported in this case, I am very confident that if the blood smear had been carefully reviewed, the author would have found the presence of rouleaux and perhaps increase in background staining (bluish tinge). Increased production of immunoglobulins by myeloma cells lead to rouleaux formation. Rouleaux is caused by an increase in cathodal proteins such as immunoglobulins. With this blood smear finding, the diagnosis of myeloma could have been reached earlier.


1. Abramson N. Rouleaux formation. Blood 2006;107:4205
2. Bain BJ. Morphology of Blood Cells. In Bain BJ, editor. Blood Cells: A Practical Guide. Oxford. Blackwell Science;1995. p. 42-131

Competing interests



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