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IgD lambda multiple myeloma causing hyperammonaemia with possibly reduced ammonium excretion
  1. Naohi Isse1,
  2. Kei Nakahara2 and
  3. Ryutaro Sasai3
  1. 1General Medicine, Okayama Kyoritsu General Hospital, Okayama, Okayama, Japan
  2. 2Toho University, Ota-ku, Tokyo, Japan
  3. 3Ako City Hospital, Ako, Hyogo, Japan
  1. Correspondence to Dr Naohi Isse; issenaohi{at}


A man in his 70s presented with impaired consciousness due to hyperammonaemia while investigating multiple tumours in his brain, chest, spine and right adrenal gland. He did not have any disorders causing hyperammonaemia, such as liver dysfunction, urea-producing bacterial infection or any medications interfering with ammonium metabolism. Blood and urine tests in addition to tumour biopsy specimens confirmed immunoglobulin D lambda multiple myeloma. His general status responded to chemotherapy using bortezomib, dexamethasone and daratumumab, and he subsequently regained full consciousness and a normalised serum ammonia level. He, unfortunately, died of refractory multiple myeloma with hyperammonaemia. The autopsy specimen revealed lambda light-chain deposits in the distal tubule epithelium with cast precipitation and intact liver cells. Urine osmolality gap analysis suggested possibly reduced urinary ammonium excretion, but further investigation is necessary to elucidate the significance of pathological renal characteristics in multiple myeloma with hyperammonaemia.

  • Haematology (incl blood transfusion)
  • Pathology
  • Acute renal failure

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  • Contributors KN and RS involved in the patient care and analysed the test results to find the novel findings. NI (guarantor) managed the patient care, drafted and edited the manuscript. All authors have approved the final manuscript for submission and are accountable for the article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.