Papular mucinosis with IgG(K) M component

A 59-year-old woman had papular mucinosis and IgG(K) M component in the serum. Only three other cases of papular mucinosis in which the IgG M component had K-type light chains have been reported. Papular mucinosis seems to be a systemic rather than a solely cutaneous disease and may be related to plasma-cell dyscrasis. Its course is usually benign and chemotherapy may have an adverse effect.

Clinical and laboratory findings in primary generalized and multiple-myeloma-related amyloidosis

Thirty-four patients with primary generalized amyloidosis (PGA) and 14 with multiple-myeloma-related amyloidosis (MRA) were studied. The commonest clinical manifestations in PGA were nephrotic syndrome, hepatomegaly and congestive heart failure, and in MRA, low back pain, plasmacytoma and rheumatoid-arthritis-like syndrome. Eight patients with PGA had limited clinical expression of the disease, such as involvement of only kidneys, joints, parotid glands or gastrointestinal tract; in one patient amyloidosis was limited to lymph nodes. Low serum concentrations of total protein and albumin were common. M components were detected in the serum of 91% of patients with PGA and 92% of patients with MRA: 70% of the M components in PGA and 25% of those in MRA had lambda light chains. Bence Jones proteinemia was detected in 56% of the patients with PGA and in 77% of those with MRA. The serum concentration of immunoglobulins was decreased substantially in more than two thirds of the patients with PGA. Proteinuria (greater than 250 mg/24 h) was observed in 78% of patients with PGA and in 93% of patients with MRA. Bence Jones proteinuria was noted in 75 and 77% of patients, respectively. Plasmacytic infiltration of the bone marrow was found in 90% of the patients with PGA. The mean survival time of the patients with PGA was 28 months and of those with MRA, 29 months from the time of diagnosis.

Clinical manifestations of multiple myeloma: relation to class and type M component

From analysis of serum samples and clinical data from 632 patients with multiple myeloma it was determined that IgG was the commonest class of myeloma and that this type seemed to be the most benign. IgD myeloma and lambda light-chain disease were the most aggressive types; patients with these types were usually younger at diagnosis and more commonly had azotemia, osteolytic lesions and Bence Jones proteinemia. The sexes were equally represented in all but IgD myeloma, in which males predominated. Prognosis was more favourable when the M component had kappa light chains.

M components-a review of 1242 cases

Among 1242 patients referred for immunologic investigation 1255 M components were detected in the serum. Of these patients 50.9% had multiple myeloma, 18.1% had nonmyelomatous malignant diseases such as macroglobulinemia, lymphoma, leukemia or cancer, 4.3% had connective tissue diseases, 2.5% had primary generalized amyloidosis (PGA) and the rest had various "benign" conditions. Whereas IgG was the commonest M component in multiple myeloma, connective tissue diseases and the other benign conditions, IgM was the commonest M component in lymphoma and leukemia; Bence Jones proteinemia was most frequently observed in PGA. The ratio of kappa to lambda light chains varied from 1.7:1 in IgG myeloma to 1:9 in IgD myeloma, and was 1:2.1 in PGA. Bence Jones protein was detected in 422 (66%) of 640 urine samples tested, the prevalence ranging from more than 70% in multiple myeloma and PGA to as low as 36% in various benign conditions. It is evident that the class and type of M components and the presence of Bence Jones proteinuria have no definite significance with regard to the diagnosis. Therefore, thorough investigation and follow-up at regular intervals are required when M components are detected.

Malabsorption syndrome with IgG(lambda) M component: response to chemotherapy

A patient with malabsorption syndrome and steatorrhea was found to have IgG (lambda) M component in the blood and some extracellular deposition of IgG in the intestinal wall. There was no evidence of multiple myeloma. He responded favourably to intermittent courses of melphalan and prednisone.

Cryocrystalglobulinemia

A 40-year-old woman had cryocrystalglobulinemia with IgG2(K1). To date, 27 other cases of spontaneous crystallization of a plasma protein have been reported. In all, the protein, a cryoglobulin, has been found to be an IgG molecule. The disease most commonly associated with this phenomenon has been multiple myeloma. None of the patients have had Raynaud's phenomenon, but many have had purpuric skin lesions made worse by exposure to cold. In the two cases of essential cryocrystalglobulinemia, crystals were found in the peripheral blood film. Immunologic, biochemical and ultrastructural studies have so far not demonstrated any property common to all cryocrystalglobulins.

Waldenström's macroglobulinemia: review of 45 cases

Of 168 patients with monoclonal IgM in the serum 45 (27%) had Waldenström's macroglobulinemia. The mean age at diagnosis was 66 years. Generalized weakness, fatigue and bleeding manifestations were the usual chief complaints. Lymphadenopathy and hepatosplenomegaly were frequent. Moderate or severe anemia was noted in 29 patients, 9 had abnormal liver function, 8 had cold agglutinemia and 7 had cryoglobulinemia. Two patients had false-positive VDRL tests. The serum concentration of IgM usually exceeded 1000 mg/dl. Comparison of IgM values obtained by immunoquantitation and electrophoresis showed two types of discrepancy: readings were too high by immunoquantitation when IgM of low molecular weight was present, and readings were too low when, probably, IgM/IgG complexes were present or the serum was hyperviscous. Bence Jones protein was detected in 71% of the urine samples tested but the concentration was usually low, exceeding 200 mg/24 h in only nine instances. The mean survival time from the time of diagnosis for the 24 patients who died was 49.5 months and for the patients who are still alive, 43 months. Survival seemed to be related to the presence of azotemia, hypoalbuminemia and abnormal liver function.

Serum viscosity and hyperviscosity syndrome in IGG multiple myeloma - the relationship of Sia test and to concentration of M component

The Sia test has been used for a long time for the diagnosis of macroglobulinemia, but its significance in myeloma is not known. It has recently been reported that the majority of sera in immunoglobulin G (IgG) myeloma with hyperviscosity syndrome are Sia-positive.

Immunochemical and physical studies of the Sia test

The Sia test was performed in strictly standardized conditions in boiled, bidistilled, deionized water (BBD) and in 0.01 M phosphate buffers pH 5.0 and 7.0. Normal human sera and sera from patients with diffuse hypergammaglobulinemia ( greater than 2.0 g/100 ml), immunoglobulin G (IgG) myeloma (M component greater than 5.0 g/100 ml), and Waldenstrom's macroglobulinemia were studied. In BBD all normal sera were Sia-negative, whereas 16 per cent of sera with diffuse hypergammaglobulinemia, 60 per cent of sera with IgG M component, and 44 per cent of macroglobulinemic sera with Sia-positive. Almost all sera from the above mentioned four groups gave positive results in phosphate buffer pH 5.0 and the majority of them, with the exception of normal human sera, gave positive results at pH 7.0. All precipitates isolated from the sera tested showed beta-alpha 2 bands in cellulose acetate electropherograms. Precipitates from the sera with diffuse hypergammaglobulinemia also showed gamma bands, and those from the myelomatous or macroglobulinemic sera showed strong bands corresponding to the M components. Whereas immunoelectrophoresis of the four-fold-concentrated precipitates showed up to 11 precipitation lines, radial immunodiffusion detected up to 18 proteins. The characteristic pattern of IgM/IgG immune complexes was observed in immunoelectrophoresis of Sia precipitates from hypergammaglobulinemic sera with rheumatoid factor. The recovery of immunoglobulins in the Sia precipitates varied greatly but that of IgM was usually greater than that of IgG or IgA. It may be concluded that the Sia test is entirely nonspecific regardless of the buffer or pH at which it is performed. The only advantages of this test seem to be the quick partial purification of IgM components and identification of their light chains, and the possible detection of immune complexes.

Heterogeneity of IgM/IgG cryocomplexes: immunological-clinical correlation

A detailed study has been made of the mixed cryoglobulins (MCs) occurring in four patients with different disease states. These included (1) macroglobulinemia of Waldenström with an IgM(K)/IgG cryocomplex containing Clq, free DNA, rheumatoid factor, anti-ssDNA and VDRL activity; (2) Peetom-Meltzer syndrome with an IgM(K)/IgG cryocomplex containing free DNA, Clq, Cls, fibrinogen, alpha2-macroglobulin and beta-lipoprotein; (3) rheumatoid arthritis with an IgM(K)/IgG cryocomplex containing rheumatoid factor, free DNA and anti-ssDNA activity; and (4) angioimmunoblastic lymphadenopathy with an IgM(K)/IgG cryocomplex containing rheumatoid factor, free DNA and anti-I cold agglutinin activity. All of these patients exhibited multisystem involvement with evidence of vascular injury. A review of the MCs found in various clinical states, reveals that whereas in systemic lupus erythematosus MCs almost invariably possess antinuclear factor activity and contain DNA as well as some components of complement, in Peetom-Meltzer syndrome MCs do not have these characteristics, but invariably have strong rheumatoid factor activity, usually absent in MCs from systemic lupus erythematosus. MCs in lymphoproliferative disorders have strong rheumatoid factor activity but not ANF activity. In infectious diseases, MCs usually exhibit strong rheumatoid factor, VDRL and cold agglutinin activity, and co-precipitate with alpha2-macroglobulin. While there is some overlap in the characteristics of MCs from various clinical diseases, the above mentioned differences are probably of some biological importance and require further investigation.

IgD deposition in glomerulonephritis. An immunopathologic study

Diffuse deposits of IgD were found in glomerular basement membranes in eight of 263 consecutive renal biopsies by the direct immunofluorescent technic. In five biopsies a granular staining pattern was found and in three a linear pattern was found. IgG and beta1C were present in glomeruli of all eight patients, and IgM in four. Two patients had elevated titers of antithyroglobulin antibodies in the serum, and one patient had anti-glomerular basement membrane antibodies of the IgG class in both serum and renal eluate. This study suggests that IgD may play a role in immunologically mediated glomerular disease. (Key words: IgD; Glomerular deposits; Nephritis.)

Treatment of plasma cell myeloma with cytotoxic agents

Because cross-resistance between alkylating agents has not been observed, we attempt in a prospective trial to determine the advantages, if any, in administering three alkylating agents sequentially, alternately, or concurrently. A patient with myeloma, showing progressive shortening of M-protein doubling time from 98 to 15 days, developed an acute terminal phase, characterized by fever and pancytopenia. A similar acute terminal phase was observed in 17 of 50 deaths from myeloma. Since alkylating agents are only effective in controlling the chronic phase of myeloma, future improvements will require the discovery of agents that delay, prevent, or are effective in the treatment of the acute phase. Forty-five patients with kappa- and 36 with lambda-light-chain disease showed no differences in frequency of amyloidosis, renal failure, response to treatment, or survival after treatment with alkylating agents.

IgD multiple myeloma. Review of 133 cases

One hundred thirty-three patients had IgD myeloma. The IgD comprises 0.8% of M-components in general and 2.1% of myelomas in particular. Males predominate and 65% of the patients are younger than 60 years at the diagnosis. More than half of the patients have lymphadenopathy, hepatomegaly, or splenomegaly. Extraosseous spread and amyloidosis are frequent. Severe anemia and azotemia are common. Total serum protein and IgD M-component levels are usually not high. LAMBDA-type light chains are found in 90% of IgD M-components. Bence Jones proteinimia is frequent and Bence Jones proteinuria appears in almost all patients. Mean survival is 13.7 months from diagnosis. The IgD is different from IgG and IgA myeloma, indicating that the clinical picture and course of multiple cyeloma may be related to the class and type of M-component.