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A bifid albumin peak of recent onset

Published:January 23, 2017DOI:https://doi.org/10.1016/j.ejim.2017.01.012

      1. Indication

      A previously healthy 29-year-old woman was admitted to the hospital for dyspnea, fever at 39 °C, arthralgia and myalgia. She had been treated one month before for a first episode of pneumonia treated with amoxicillin 3 g daily for 10 days. Clinical examination was normal, thoracic CT scan showed patchy bilateral areas of consolidation, nodular opacities, bronchial wall thickening, and small left pleural effusion. Routine blood examination showed a leukocyte count of 10,200/mm3 with 5830 neutrophils/mm3, serum creatinine was normal, and C reactive protein level was 65 mg/L. All infectious investigations were negative. The patient recovered under amoxicillin/clavulanic acid 1 g/125 mg 3 times daily for 14 days and rovamycin for 7 days. One month later physical examination was unremarkable, blood examination results were within normal ranges but serum protein electrophoresis showed the presence of bifid albumin bands while it was normal previously (Fig. 1).
      Fig. 1
      Fig. 1Serum protein electrophoresis (Sebia capillary electrophoresis instruments, CAPILLARYS) shows the presence of the presence of a double albumin band. Such a pattern was not observed initially on admission (in insert).

      2. What is the diagnosis?

      2.1 Diagnosis

      Acquired bisalbuminemia induced by beta-lactam antibiotics was diagnosed.
      Bisalbuminemia (also termed alloalbuminemia) is a rare inherited or acquired abnormality of the serum protein electrophoresis, with bifid peak due to the presence of two distinct fractions of albumin with a different mobility. Hereditary bisalbuminemia is an autosomal dominant condition, related to an abnormal mutant of albumin, usually discovered fortuitously, but point mutations can be associated with hyperthyroidism [
      • Sunthornthepvarakul T.
      • Likitmaskul S.
      • Ngowngarmratana S.
      • et al.
      Familial dysalbuminemic hypertriiodothyroninemia: a new, dominantly inherited albumin defect.
      ], because of altered binding of steroid hormones and thyroxine. Acquired or transient bisalbuminemia has been described in several pathological conditions including diabetes mellitus, chronic renal failure, nephrotic syndrome, and pancreatic diseases, diabetes mellitus, Waldenstrom's macroglobulinemia, and multiple myeloma, [
      • Winter V.
      • Rosenvall A.
      • Heikkilä S.
      • von Essen R.
      Acquired bisalbuminemia in staphylococcal endocarditis treated with dicloxacillin.
      ,
      • Rocha J.
      • Bohner J.
      • Kömpf J.
      Transient bisalbuminemia: separation by isoelectric focusing of human albumin fractions linked to different numbers of benzylpenicilloyl groups.
      ] but also in patients under β-lactam antibiotics. Indeed the antibiotic reversibly binds to serum albumin, with a negative charge exerted by the free carboxylic acid group of penicillin upon the protein, and a faster mobility [
      • Winter V.
      • Rosenvall A.
      • Heikkilä S.
      • von Essen R.
      Acquired bisalbuminemia in staphylococcal endocarditis treated with dicloxacillin.
      ,
      • Rocha J.
      • Bohner J.
      • Kömpf J.
      Transient bisalbuminemia: separation by isoelectric focusing of human albumin fractions linked to different numbers of benzylpenicilloyl groups.
      ]. In this setting, bisalbuminemia is mainly observed in patients receiving high doses of β-lactam antibiotics or with renal failure. It appears from 3 to 8 days and disappears weeks or months after the end of treatment. Physician should be aware of this entity.

      References

        • Sunthornthepvarakul T.
        • Likitmaskul S.
        • Ngowngarmratana S.
        • et al.
        Familial dysalbuminemic hypertriiodothyroninemia: a new, dominantly inherited albumin defect.
        J Clin Endocrinol Metab. 1998; 83: 1448-1454
        • Winter V.
        • Rosenvall A.
        • Heikkilä S.
        • von Essen R.
        Acquired bisalbuminemia in staphylococcal endocarditis treated with dicloxacillin.
        Scand J Infect Dis. 1992; 24: 811-814
        • Rocha J.
        • Bohner J.
        • Kömpf J.
        Transient bisalbuminemia: separation by isoelectric focusing of human albumin fractions linked to different numbers of benzylpenicilloyl groups.
        Electrophoresis. 1995; 16: 1031-1033