[A case of Crow-Fukase syndrome with respiratory failure due to bilateral diaphragmatic paralysis]

A 62-year-old man with well-controlled diabetes mellitus developed numbness of the bilateral feet and hands, followed by subacutely progressive weakness and amyotrophy of extremities. He became bed-ridden state, and dyspnea also appeared, so he was referred to our hospital. Physical examination revealed a lean man, with dark-reddish skin pigmentation, crabbed fingers, bilateral pretibial pitting edema, and bristles in extremities. Thoracoabdominal paradoxical respiration was observed and pulmonary vesicular sounds was decreased markedly in the both lungs. Laboratory data revealed hypoproteinemia, abnormalities of endocrine system, but M-protein was not detected. Serum vascular endothelial growth factor level was quite high. Chest radiography revealed elevation of the bilateral diaphragm, the % vital capacity (%VC) was 24%, and arterial blood gas analysis showed marked hypoxia with hypercapnia. These findings suggested that his respiratory failure was induced by bilateral diaphragmatic paralysis caused by bilateral phrenic nerve palsy due to Crow-Fukase syndrome. He became somnolent because of hypercapnic narcosis, so non-invasive positive pressure ventilation (NIPPV) was started. We treated him with intravenous immunoglobulin and oral corticosteroids therapies, and after these therapies, his symptoms were remarkably recovered and NIPPV became unnecessary soon. The most frequent causes of respiratory failure in Crow-Fukase syndrome are pleural effusion and pulmonary hypertension, and only two cases of this syndrome with respiratory failure caused by bilateral diaphragmatic paralysis were reported until now. When the patients with Crow-Fukase syndrome complain of dyspnea, we should take the diaphragmatic paralysis into consideration, which may be improved by appropriate therapies.

[A man with plasma cell dyscrasia and polyneuropathy due to POEMS syndrome]

In a 52-year-old man with general malaise, muscle stiffness and weakness, POEMS-syndrome was diagnosed based on polyneuropathy, splenomegaly, lymphadenopathy, subclinical hypothyroidism and the presence of a monoclonal paraprotein with osteosclerotic lesions and an indurated skin (POEMS is an acronym for Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal protein, Skin changes). This is a rare systemic disease from the clinical spectrum of plasma cell dyscrasias with polyneuropathy. The clinical picture is broader and more pleomorphic than the acronym suggests. The possibility of a POEMS syndrome should be considered in the differential diagnosis of polyneuropathy in association with monoclonal gammopathy. Quite often it is associated with osteosclerotic myeloma or mixed osteoscleroticlytic lesions. The patient described was treated with high dose corticosteroids which were gradually decreased over the next three months, upon which a marked improvement could be seen. The general malaise subsided, as did the splenomegaly, and the skin became supple again.

[Vascular endothelial growth factor and Crow-Fukase syndrome]

Serum vascular endothelial growth factor (VEGF) is highly elevated in patients with Crow-Fukase syndrome (CFS) and is well correlated with the clinical manifestations of CFS. In circulating blood, VEGF is specifically stored in platelets and released during platelet aggregation. To clarify the role of VEGF in the pathomechanism of CFS, we transplanted VEGF secretion tumors in nude mice and studied the pathological findings in these mice. Prominent edema with elevated serum VEGF were found. Organomegaly was also found in liver, spleen and kidney. Pathological findings in these organs were similar to those found in autopsies of CFS patients. In peripheral nerve, mild intraneural edema was seen, however, neuropathy was not prominent. These findings suggest that elevated VEGF may be closely correlated with generalized edema (anasarca). However, it is also important to consider factors such as cytokines and other T cell functions that, in association with VEGF, may be the cause of neuropathy in CFS.

[A patient with Crow-Fukase syndrome associated with pulmonary plasmacytoma]

We here reported a 54-year-old female patient with Crow-Fukase syndrome associated with pulmonary plasmacytoma. She was found to have scattered tumor in 1990. Although the tumor had slowly grown for the last 10 years, she showed no clinical symptoms. Numbness and weakness of lower extremities began in June 1999, and she was referred to Kyoto University Hospital on Oct. 21 1999 for evaluation of progressive symptoms. She had skin pigmentation, edema of the lower extremities, lymphadenopathy, muscle weakness and sensory disturbance in a glove-and-stocking distribution. Serological examination showed monoclonal IgG-lambda gammopathy. Serum vascular endothelial growth factor (VEGF) was markedly elevated. Microscopic studies on biopsied sural nerve demonstrated mild decrease of myelinated fibers. Immunohistochemically, the pulmonary tumor was defined as an IgG (lambda type) plasmacytoma. After treatment with melphalan-prednisolone therapy, the neurological symptoms improved along with decrease of serum VEGF levels as well as the size of pulmonary plasmacytoma. This is the first report of a patient with Crow-Fukase syndrome associated with pulmonary plasmacytoma. This case suggests that growth of pulmonary plasmacytoma might have played an important role in the overproduction of VEGF and thus development of Crow-Fukase syndrome.

[POEMS syndrome]

Poems syndrome is a rare multisystemic disorder. It manifestations are Polyneuropathy, Organomegaly, Endocrinopathy, and/or Edema, Monoclonal protein and changes in the Skin. (P.O.E.M.S.) Though some bibliography make no difference with osteoesclerotic myeloma it is considered a real syndrome. The polyneuropathy is customarily severe. Although high levels of immunoglobulins has been found in the poems, it has not been isolated a specific antibody that explain the polyneuropathy even though it is strongly suspected. The organomegaly, endocrinopathy, changes in the skin and other systems and involved organs could be in relationship to products secreted by plasmatic cells. We review the physiopathology and bibliography of the Poems, especially its neurological expression its nosologic location different from osteosclerotic myeloma and a possible relationship to the Herpes Virus 8. It was crossed in Medline the terms P.O.E.M.S. and syndrome and were obtained 271 abstracts that were all examined and finally selected the bibliography considerate meaningful for the objectives. It is presented briefly a case. P.O.E.M.S. is a syndrome that is associated to multiple plasma cell dyscracia, included the osteoesclerotic myeloma. Prognosis and the treatment vary with the underlying disease. As physiopathology of this syndrome is insinuated the action of the interleukins 1-beta (IL-1 beta) and 6 (IL-6), the vascular growth endothelial factor (VGEF), the tumoral necrosis factor alpha (TNF-alpha) and antibodies anti-nerve. The P.O.E.M.S. is a syndrome with own identity. The Herpes Virus 8 may plays a key rol to uncover the Poems physiopathology.

POEMS syndrome: cicatricial alopecia as an unusual cutaneous manifestation associated with an underlying plasmacytoma

POEMS syndrome is a rare condition with cutaneous manifestations commonly including angiomas, hypertrichosis, hyperpigmentation, and thickening of the skin. We describe a male patient with a 2-year history of cervical lymphadenopathy, erythematous thickening of the skin on the neck, and progressive walking difficulties. The patient had an occipital erythema with scarring alopecia and sparse follicular pustules at the edge of the lesion. Further investigation revealed symmetric polyneuropathy, hepatosplenomegaly, monoclonal gammopathy, subclinical thyreopathy, and an osteolytic bone lesion of the skull. Histologically, a plasmacytoma with lambda cell restriction was found. The overlying skin showed marked fibrosis, with loss of hair follicles, and a plasma cell infiltrate of polyclonal origin. The cervical lymph nodes showed histologic characteristics of multicentric Castleman's disease, and the skin of the neck showed thickening and vasoproliferation. There was no evidence of further plamacytomas. After excision of the plasmacytoma and postoperative irradiation, the symptoms gradually resolved within a few months. A cicatricial lesion remained on the occiput without further folliculitis or hair loss on the rest of the scalp. This case illustrates the reactive character of POEMS syndrome as a paraneoplastic syndrome in myeloma patients.

[POEMS-Syndrome--unusual manifestation with bilateral Charcot's Joint]

HISTORY AND CLINICAL FINDINGS

A 45-year-old patient with no significant past medical history was admitted 8 weeks after minor foot trauma with injury of the left ankle joint with massive destructive arthropathy. On admission the arch of both feet was flattened and both feet showed massive painless soft tissue swelling. Due to loss of muscle strength elevation of feet and toes was reduced and there was a "stocking-like" loss of sensation of the lower extremity. The gait was ataxic. No other abnormalities were detected besides hepatomegaly and hyperhidrosis.

INVESTIGATIONS

Advanced polyneuropathy was confirmed by nerve conduction study. Laboratory tests revealed paraproteinaemia type IgG-lambda. Bone marrow biopsy, bone scan and skeletal survey did not provide additional information. Sonography confirmed hepatosplenomegaly, endocrinological work up showed impaired glucose tolerance and lowered testosterone levels. Based on these findings the diagnosis of POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M-protein and skin changes) was established.

TREATMENT AND COURSE

Plasma exchange was unsuccessful and due to worsening of the symptoms long term treatment with cyclophosphamide was started. Furthermore the patient received NSAIDs for symptomatic relief and orthopedic shoes. One year after initial presentation the patient continues to walk.

CONCLUSION

Usually neurogenic arthropathy is associated with diabetes mellitus, syringomyelia or with infections. Our report illustrates that POEMS syndrome might present with Charcot arthritis.

[Increased vascular endothelial growth factor (VEGF) is causative in Crow-Fukase syndrome]

Crow-Fukase syndrome is a rare multisystem disorder characterized by polyneuropathy, organomegaly, endocrinopathy, skin changes and M-protein. We have examined levels of vascular endothelial growth factor/vascular permeability factor (VEGF) in serum with Crow-Fukase patients. Serum VEGF levels in Crow-Fukase syndrome were about 15 to 30 times higher than control and other neurological disorders. Most of the characteristic manifestations may be well explainable by the biological function of VEGF except polyneuropathy. We examined the direct effects of VEGF on blood nerve barrier function using blood brain barrier model of rat and intraneural injection of recombinant VEGF. As the result, VEGF affected blood nerve barrier and increased microvascular permeability, thereby inducing endoneurial edema. After increasing the permeability of the blood nerve barrier by VEGF, serum components toxic to nerves such as complements and thrombins may induce nerve damage. Our results suggest that overproduction of VEGF plays an important role in the pathogenesis of Crow-Fukase syndrome.

[Recent advance in neuroimmunology]

Many important reports have been published during these several years in Japan in the field of neuroimmunology. Serum vascular endothelial factor (VEGF) levels in Crow-Fukase (POEMS) syndrome were about 15 to 30 times than those in the control subjects and other neurological disorders. The overproduction of VEGF may be relevant to the pathogenesis of most of the manifestations including neuropathy. We speculate that VEGF may affect the blood nerve barrier by increasing microvascular hyperpermeability and thereby increasing endoneural pressure subsequent to edema. In Isaacs' syndrome, voltage-gated potassium channel (VGKC) were suppressed by anti-VGKC antibodies. The patch clamp study indicate that the pathophysiology of the suppression of VGKC seems to be due to the increased degradation of VGKC. By the recent nationwide survey, the total number of HTLV-I-associated myelopathy (HAM) patients in Japan is now estimated as 1,432. A most likely pathological mechanism of HAM is that cytotoxic T lymphocytes attack the HTLV-I infected lymphocytes infiltrating the central nervous system, resulting a surrounding nervous tissue damage by bystander mechanism.

Overproduction of vascular endothelial growth factor/vascular permeability factor is causative in Crow-Fukase (POEMS) syndrome

Crow-Fukase or POEMS syndrome of polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes is a rare multisystem disorder of obscure pathogenesis that is associated with microangiopathy, neovascularization, and accelerated vasopermeability. We examined the levels of the vascular endothelial growth factor/vascular permeability factor (VEGF) in the serum and cerebrospinal fluid (CSF) from 10 patients with this syndrome. Serum VEGF levels were about 15-30 times those in control subjects or patients with Guillain-Barré syndrome (GBS), chronic inflammatory demyelinating polyneuropathy (CIDP), and other neurological disorders. The CSF VEGF levels, however, were similar to those found in GBS and CIDP. Elevated VEGF levels in the serum decreased in 7 patients with Crow-Fukase syndrome after conventional therapy. The principal isoform of VEGF in Crow-Fukase syndrome was VEGF165. Elevated VEGF was independent of M-protein. Our results suggest that the overproduction of VEGF is important in the pathogenesis of this disorder.

Neurological manifestations of malignant and non-malignant dysglobulinaemias

The main neurological manifestations associated with malignant and non-malignant dysglobulinaemias are reviewed. These disorders are classified according to topographic features, pathological changes or association with specific plasma cell disorders. The main clinical, laboratory, immunological and pathological features are summarized. Knowledge of the pathogenesis in this group of disorders has clearly increased in recent years, allowing better diagnosis and treatment.

POEMS syndrome in a patient with diabetic ketoacidosis: case report and review

POEMS syndrome is an uncommon multisystem disorder characterized by the combination of polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes. A 57-year-old man diagnosed with POEMS syndrome after presenting with diabetic ketoacidosis and characteristic skin lesions is reported. The dermatologic and systemic manifestations of this unusual syndrome are reviewed.

POEMS syndrome, steroid-dependent diabetes mellitus, erythema elevatum diutinum, and rheumatoid arthritis as extramedullary manifestations of plasma cell dyscrasia

POEMS syndrome is a rare synopsis of different multisystemic disorders (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammapathy, and skin lesions) associated with plasma cell dyscrasia. We herein report the atypical case of a 44-year-old white man presenting with glomerulopathy, POEMS syndrome, and erythema elevatum diutinum with a few-year history of non-insulin-dependent diabetes mellitus (NIDDM) and seronegative rheumatoid arthritis (RA) as early manifestations of IgAlambda multiple myeloma. The prescription of 1 mg/kg/day prednisone improved the patient's features dramatically. Skin lesions improved by the association of glucocorticoids and plasma exchange, recurred when plasmapheresis ceased, and remitted when plasma exchange was reintroduced. NIDDM requiring insulinotherapy recurred when corticoids were discontinued and remitted when prednisone was reintroduced. However, prednisone and plasmapheresis had no effect on polyneuropathy, M-paraprotein, and plasma cell dyscrasia in our patient, who developed indolent multiple myeloma a few years later. We thus concluded that POEMS syndrome, steroid-dependent diabetes mellitus, rheumatoid arthritis, RA, and skin vasculitis in our patient were triggered by plasma cell dyscrasia.

[Poems syndrome: a case report]

INTRODUCTION

The Poems syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammapathy and skin changes) is an uncommon multisystemic disorder. Usually it is a manifestation of a type of myeloma of which the chief characteristic is the presence of osteosclerotic lesions, classically seen radiologically to be single or multiple. Nowadays, not only is Poems considered to be a manifestation of osteosclerotic myeloma, but may also be seen associated with other plasma cell dyscrasias.

CLINICAL CASE

We present a case of Poems syndrome secondary to a plasmocytoma of the dorsal vertebral column in a 32 year old male negro. Initially he had sensori-motor polyneuropathy associated with other features characteristic of the syndrome (organomegaly, IgA monoclonal gammapathy and skin changes). Later he also showed signs attributed to a compressive lesion of the dorsal spinal medulla. An unusual finding in this patient was that the bony lesion was predominantly osteoclytic.

CONCLUSIONS

We briefly review the syndrome and comment on the diagnosis.

[A case of POEMS syndrome with various complications]

A 65-year old man presented with complaints of sclerosis of skin and numbness in the extremities. During last 10 year, he had developed monoclonal gammopathy, Raynaud's phenomenon, ischemic heart disease, sigmoid colon cancer, hyperkalemia, polyneuropathy and scleroderma-like skin changes. Laboratory examinations revealed a monoclonal protein (IgA-lambda) and an elevated serum level of IL-6. Subsequently a diagnosis of POEMS syndrome was made based on the clinical features and laboratory findings which were characteristic of this syndrome. Further examinations showed the presence of glomerulonephritis and brain tumor. These various complications are of great interest in understanding the pathogenesis of POEMS syndrome.

Osteosclerotic myeloma and 'POEMS' syndrome

Metabolic bone disease is a major cause of morbidity and mortality in patients suffering from multiple myeloma. This usually results from an imbalance between the osteoclast and osteoblast activity of bone resorption and formation due to the secretion of an osteoclast-activating factor by the myeloma cells. This generally takes the form of lytic lesions, hypercalcaemia and osteoporosis but, in a minority of patients, osteosclerosis is a striking feature. In a proportion of patients with gammopathy and the osteosclerotic form of the disease, there appears to be an association with other symptom complexes including Polyneuropathy, organomegaly, endocrine changes, and skin abnormalities. This article summarizes the clinical, radiological and laboratory features of this syndrome, which is known by the acronym 'POEMS'. It is important to recognize this condition, as it carries a better prognosis than the more common lytic form of the disease and because vincristine, and agents frequently used to treat this condition, may severely exacerbate the neuropathy and should be avoided. This syndrome is also important because it may give some insight into the pathophysiology of the plasma-cell dyscrasias.

[Pro-inflammatory cytokines: a pathogenic key of POEMS syndrome]

The Polyneuropathy, Organomegaly, Endocrinopathy, M protein, Skin changes (POMEMS) syndrome is a rare multisystem disorder of obscure pathogenesis, associated with osteosclerotic myeloma. Unlike multiple myeloma without neuropathy, circulating levels of proinflammatory cytokines (IL-1 beta, TNF-alpha IL-6) are increased in patients with POEMS syndrome. Sites of IL-1 beta production include lymph node and bone marrow tissues. These data support the view that pleiotropic effects of proinflammatory cytokines released secondary to a strong activation of the monocyte/macrophage system, take part in the multisystemic expression of the disease.

POEMS syndrome and Waldenström's macroglobulinaemia

A 58 year old man presented with a three year history of impotence, night sweats and ankle swelling. On examination, the patient fulfilled the diagnostic criteria for POEMS syndrome, but was unusual in that he also had underlying Waldenström's macroglobulinaemia with IgM kappa paraproteinaemia. The patient was treated with intermittent chlorambucil and made a good recovery. POEMS syndrome has been described in association with osteosclerotic myeloma and Castleman's disease. The paraprotein involved is usually IgG or IgA with lambda light chains. This case indicates that the presence of lambda light chains is not essential for the pathogenesis of POEMS syndrome. It also emphasises the diversity of plasma cell dyscrasias that can manifest as POEMS syndrome.

Multiple autoimmune manifestations in monoclonal gammopathy of undetermined significance and chronic lymphocytic leukemia

In 18 cases of monoclonal gammopathy of undetermined significance, MGUS (monoclonal gammopathy of undetermined significance), admitted for diagnosed or suspected peripheral neuropathy, 11 patients showed other co-existing autoimmune manifestations. Two had POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M-component, and skin symptoms), the others mainly endocrinopathy and polyclonal pseudolymphoma. There were 13 cases of sensorimotor neuropathy, two cases of neuritis, while neuropathy could not be confirmed in three cases. Compared with a retrospective review of autoimmunity in a randomly selected CLL (chronic lymphocytic leukemia) cohort of 115 patients, 13 out of 42 patients with clinical and/or laboratory features of autoimmunity showed co-expression of autoimmune signs, the dominating traits being Coombs positive AIHA (auto-immune hemolytic anemia), platelet autoantibodies, endocrinopathy mainly associated with the thyroid gland, serological and/or rheumatological symptoms, but only one case of sensorimotor neuropathy. Viewed from a current model of acquired autoimmunity it is perhaps not surprising that such autoimmunity is seen predominantly in patients with monoclonal gammopathy. Thus, a high concentration of cross-reacting polyreactive autoantibodies related to the M-component might be present in these patients. Furthermore, quantitative defects of the immunoglobulins including the hypogammaglobulinemia associated with M-components can presumably give rise to a defect of the anti-idiotypic network's regulation of natural autoantibodies and autoimmune manifestations in vivo. Such autoimmune manifestations, which are easily overlooked in CLL may call for additional treatment with immunosuppression and/or intravenous, polyclonal IgG.