Pseudo-hyponatremia is an uncommon laboratory finding that can lead to serious morbidity and mortality if not recognized abruptly. Often linked to conditions like hyperlipidemia or hyperproteinemia, pseudohyponatremia can mislead clinicians and result in misdiagnosis. We discuss this through two real-world case studies, explaining how it develops and how to diagnose it accurately. It\'s paramount that clinicians recognize and properly differentiate pseudohyponatremia from true hyponatremia to prevent wrong treatments. We stress the need to address the root causes in order to provide the optimal patient care.

UNASSIGNED: Even in the absence of other symptoms or other pulmonary manifestations suggesting Sjögren\'s syndrome (SS), it is necessary to include SS in the differential diagnosis of diffuse cystic lung disease (CLD).
UNASSIGNED: A case of SS that presented initially with diffuse CLD is reported. This case is considered rare because diffuse pulmonary cysts were observed in the early stage with few symptoms, only cysts were observed without other lung lesions on imaging, cyst formation was histologically considered to be alveolar loss, and airway lesions not observed on imaging were suspected based on lung function testing. The details of this case provide extremely important information to consider for the diagnosis and management of CLD and SS.

BACKGROUND: Hyperglobulinemia is reported in 26% of canine chronic B-cell lymphocytic leukemia (B-CLL) cases. However, few cases have been characterized by protein electrophoresis and immunofixation (IF), and the incidence of a monoclonal protein (M-protein) is unknown using these techniques.
OBJECTIVE: To characterize and determine the proportion of canine B-CLL cases with an M-protein using plasma protein electrophoresis (PPE), routine and free light chain (fLC) IF, and to assess if productive B-CLL cases express MUM1/IRF4 by cell tube block (CTB).
METHODS: PPE, routine (targeting IgG, IgA, IgM, IgG4, and light chain) and fLC IF were performed using 48 dog B-CLL plasma samples from patients diagnosed via peripheral blood flow cytometry. CTB was performed on a separate cohort of 15 patients.
RESULTS: Hyperproteinemia (>7.5 g/dL) was present in 17/48 cases (35%). An M-protein was detected in 32/48 cases (67%). Of these, 19/32 cases (59%) had only complete (monoclonal heavy and light chain) M-proteins detected, 10/32 cases (31%) had both complete and fLC M-proteins detected, and 3/32 cases (9%) had only an fLC M-protein detected. IgM was the most common clonal immunoglobulin isotype detected (23 cases). CD21+ cell counts were higher in cases with detectable M-protein. Plasma fLC IF suggested β-γ region interference, likely caused by clotting proteins. All B-CLL cases consistently expressed PAX5 and did not express MUM1/IRF4.
CONCLUSIONS: Most B-CLL cases had an M-protein and were not hyperproteinemic. Most cases with paraproteins had a complete IgM monoclonal gammopathy; a subset had documented fLCs. The prognostic significance of heavy and fLC presence should be evaluated.

Serum sodium assay is a commonly performed laboratory test in a clinical setting and the results are taken for granted without being aware of the actual methods involved. In conditions like hyperlipidemia and hyperproteinemia, excessive lipids in serum dilute the water component of the serum. Since sodium is dissolved only in the aqueous phase of serum, the sodium content per unit volume of plasma is reduced. Currently, most of the laboratories use the indirect ion-selective electrode method (ISE), where the plasma sample is diluted before the measurement. Indirect ISE may not give accurate results in conditions with higher serum lipid and protein levels. Overcorrection of the serum sodium levels in pseudohyponatremia may cause serious complications. We report a case of a 26-year-old Asian male with a past medical history of chronic pancreatitis, familial hypertriglyceridemia, and fatty liver who presented to the emergency department with acute pancreatitis. Initially, the patient was found to have hyponatremia and he was started on hypertonic saline for one day. Later the patient\'s condition deteriorated and then it was determined that serum sodium results were a measurement artifact since the patient had extremely high levels of triglycerides. After realizing that it was a measurement artifact, the saline infusion was stopped and he was started on desmopressin. However, the patient deteriorated neurologically and expired later. As this patient had normal sodium levels, administration of hypertonic saline led to a fatal outcome.

Objectives  We aim to report the simultaneous effect of different protein and lipid concentrations on sodium (Na + ) and potassium (K + ) measurement by direct and indirect ion selective electrodes (dISE and iISE) in patient samples. Materials and Methods  Na + and K + were measured in 195 serum samples received in the laboratory using iISE by Roche Modular P800 autoanalyzer and using dISE by XI-921 ver. 6.0 Caretium electrolyte analyzer. Serum total protein (TP), cholesterol (Chol), and triglycerides (TG) were measured using conventional photometric methods on Roche Modular P800 autoanalyzer. Differences for each pair of results for Na + (Diff_Na + = [Na + dISE- Na + iISE ]) and K + (Diff_K + = [K + dISE- K + iISE ]) were calculated. Patient subgroups with high, normal, or low TP (< 5, 5-7.9, or ≥ 8 g/dL), Chol (< 150, 150-299, or ≥300 mg/dL), or TG (< 150, 150-299, or ≥300 mg/dL) were compared using analysis of variance. Note that 95% confidence interval of Diff_Na + and Diff_K + were calculated to see the number of samples showing clinically significant differences. Results  Diff_Na + ( p = 0.007) and Diff_K + ( p = 0.002) were found significant between samples with normal and high TP. However, effect of TG was not significant. Chol concentration affected Diff_Na + significantly between low versus normal ( p = 0.002), and high versus normal ( p = 0.031) Chol groups. Diff_K + was significant ( p = 0.009) between low versus normal Chol. Clinically relevant disagreement of ≥|5| mmol/L for Na + was observed in high percentage of samples including all subcategories; however, for K + only 3.6% of the total samples showed disagreement of ≥ |0.5| mmol/L. A multivariate regression equation based on fit regression model was also derived. Conclusion  Summarily, interchangeable use of electrolyte results from dISE and iISE is not advisable, especially in a setting of hyperproteinemia (≥8 g/dL) or hypercholesterolemia (≥300 mg/dL); more so for Na + .

Hyperproteinemia is a severe metabolic disease characterized by abnormally elevated plasma protein concentrations (PPC). However, there is currently no reliable animal model for PPC, and the pathological mechanism of hyperproteinemia thus remains unclear. In this study, we evaluated the effects of hyperproteinemia on reproductive development in an invertebrate silkworm model with a controllable PPC and no primary disease effects. High PPC inhibited the synthesis of vitellogenin and 30K protein essential for female ovarian development in the fat body of metabolic tissues, and inhibited their transport through the hemolymph to the ovary. High PPC also induced programmed cell death in testis and ovary cells, slowed the development of germ cells, and significantly reduced the reproductive coefficient. Furthermore, the intensities and mechanisms of high-PPC-induced reproductive toxicity differed between sexes in this silkworm model.

Hyperproteinemia, which is characterized by an abnormally elevated plasma protein concentration (PPC), is a high-mortality, metabolic complication associated with severe liver and kidney disease. It is difficult to clinically distinguish the difference between the impacts of primary diseases and hyperproteinemia on tissues and organs, and there are no available animal models of hyperproteinemia. Here, we constructed an animal model of hyperproteinemia with a controllable PPC and no primary disease effects in the silkworm Bombyx mori that has attracted interest owing to its potential use in the pathological analysis of model animals. Silkworm have an open circulatory system in which each organ is directly immersed in hemolymph. The fat body (FB) of a silkworm, as a major organ for nutrient storage and energy metabolism, can effectively reflect hyperproteinemia-induced metabolic abnormalities in damaged visceral tissues. A pathogenesis study showed that hyperproteinemia attenuated cell autophagy and apoptosis by attenuating an endocrine hormone, thereby preventing FB remodeling during metamorphosis. Meanwhile, hyperproteinemia increased oxidative stress in the FB and resulted in a dysfunction of amino acid conversion. Supplementation with exogenous 20-hydroxyecdysone effectively mitigated the hyperproteinemia-mediated inhibition of FB remodeling.

Three dogs were evaluated for severe hyperproteinemia and hyperglobulinemia secondary to Leishmania infantum. Double filtration plasmapheresis (DFPP) was performed in two dogs at days 1, 2, and 6 after presentation. The third dog received DFPP at days 1 and 3 after presentation and eleven hemodialysis treatments. Significant reduction in serum total protein (p ＜ 0.0001), alpha-1 (p = 0.023), alpha-2 (p = 0.018), gamma globulins (p = 0.0105), and a significant increase in albumin/globulin ratio (p = 0.0018) were found. DFPP may be a promising therapeutic technique for rapid resolution of signs of hyperproteinemia in dogs affected by L. infantum.

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BACKGROUND: Serum blood collection tubes with separator gel are widely used by many laboratories for chemistry analyses. We describe a case of a primary blood collection tube filled with blood sample and a floating separator gel.
METHODS: The blood sample was collected from a 51 years old female in intensive care unit with the diagnosis of pneumonia into a BD Vacutainer SST tube (Becton Dickinson, NJ, USA) containing serum separator gel and conveyed to the core laboratory of Marmara University Hospital within 30 minutes from collection. Sample was immediately centrifuged at room temperature at 1500 × g for 10 minutes.
RESULTS: The analyses revealed a highly increased total protein concentration of 145 g/L (reference interval 64-83 g/L). The nephelometric analyses showed an elevated serum IgG concentration of 108 g/L (reference interval 6.5-16 g/L) and IgG lambda monoclonal band was determined by serum immunofixation electrophoresis.
CONCLUSIONS: Limitation of the separator gel tubes in patients with a high plasma density and its possible effects on test results and laboratory costs should be remembered. The clinical diagnosis stated in the information system should also reveal known comorbid conditions besides the apparent admission reason. This information would avoid resampling, additional testing, and communication efforts with the clinicians.