The recent discussion regarding the utility of the inflammatory markers erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and plasma viscosity1,2 is very interesting as we have often noted them to be normal despite underlying pathology.
In our local laboratory, serum globulin is presented as part of the liver function test panels calculated by subtracting the albumin concentration from the serum total protein. We have found raised levels of total globulin to be a very useful marker of underlying blood-borne virus (BBV) infections, monoclonal gammopathy of unknown significance (MGUS), and multiple myeloma. In our two South East London practices (total population approximately 15 000) we reviewed two late diagnoses of HIV and myeloma and noted a chronically raised globulin that had been overlooked. We therefore invited patients who had a raised globulin result in their latest liver function tests from the last 3 years for a blood-borne virus screen (HIV, hepatitis B, and hepatitis C) and myeloma screen (protein electrophoresis and immunofixation). The search and recall found that across both practices 223 patients had a raised globulin of >35 g/L with no known cause in the last 3 years. Consenting to the further blood tests were 173 patients. Subsequently 39/173 (22.5%) patients were found to have underlying pathology: seven new cases of myeloma were detected, one of which required immediate treatment, and 15 patients were found to have previously undiagnosed HIV, hepatitis B, or C. The other 17 patients have been diagnosed with MGUS and are now being followed up. Interestingly, most of the above patients had normal CRP and ESR where it had been tested. We believe that this overlooked marker of underlying inflammation deserves further investigation and its utility highlighting. We have noted that there is a trend to remove globulin from routine biochemistry liver profiles as part of demand management and on cost grounds. This could potentially result in missed opportunities to diagnose cases earlier.
- © British Journal of General Practice 2019