Meningeal involvement in IgD myeloma with cerebrospinal fluid paraprotein analysis

IgD kappa myeloma: a new case

IgD myeloma, which is particularly severe, accounts for only 1-3% of all myeloma cases, and the kappa subtype contributes only 10-30% of IgD myelomas. We report a new case.

CASE-REPORT

A 59-year-old man was admitted for inflammatory low back pain with L5 sciatica and diffuse bone pain. The symptoms had been present for 3 months, during which he had experienced a severe decline in general health. Laboratory test abnormalities included an erythrocyte sedimentation rate of 70 mm/h, normochromic normocytic aplastic anemia, hypercalcemia (3.5 mmol/l), and serum creatinine elevation to 583 micromol/l. Tests were negative for cryoglobulinemia. Serum protein electrophoresis showed hypergammaglobulinemia but no monoclonal peak. Immunoelectrophoresis, however, detected a faint IgD kappa band in the blood and a homogeneous kappa band in the urine. Bone marrow aspirated from the sternum was found to contain 30% of malignant plasma cells. Biopsies for amyloidosis were negative. Radiographs disclosed multiple punched-out lesions with no evidence of spinal cord compression. Symptomatic treatment was given to correct the hypercalcemia, and combination chemotherapy was started.

DISCUSSION

IgD kappa myeloma is a severe variant of myeloma often associated with extraosseous lesions, renal failure, and amyloidosis. The monoclonal component is absent or faint by serum protein electrophoresis, making the diagnosis difficult. The pathogenesis is unclear and the prognosis grim.

Meningeal relapse after double peripheral blood stem cell transplantation in IgD myeloma

A 54-year-old man diagnosed with IgD myeloma (stage IIIA) in complete remission (CR) received peripheral blood stem cell transplantation (PBSCT) twice with an interval of 4 months using high-dose melphalan 200mg/m2. However 9 months after the second PBSCT, he was readmitted because of lumbago, lower left hemiparesis, speech disturbance and left facial nerve palsy. A lumbar puncture revealed myeloma cells in the cerebrospinal fluid (CSF). The patient did not respond to any salvage chemotherapy and died of sepsis 27 months after the initial diagnosis. The findings in this patient suggest that another treatment modality including prophylactic intrathecal injection of an anti-cancer drug as well as allogeneic cell therapy is probably necessary in patients with high-risk IgD myeloma.

Malignancy: Meningeal Myeloma: A Case Report and Review of Literature

Purpose: Report and review of an uncommon complication of multiple myeloma. Methods: We report a case of leptomeningeal myeloma and using Medline, review previously reported cases. Results: We found 35 previously reported cases of meningeal myeloma. Of the 36 cases, including the present case, the male to female ratio was 2:1 with a median age of 58 years (range, 31 to 83 years). Forty five percent of the patients had circulating plasma cells and 90.9% had plasma cells in the cerebrospinal fluid. All but 4 cases were diagnosed antemortem. Thirty patients had a pre-existing diagnosis of multiple myeloma, while leptomeningeal disease was the presenting feature in six. Management included a combination of intrathecal chemotherapy and radiation therapy, radiation therapy alone or intrathecal chemotherapy alone in 14, 3, and 3 patients respectively. Thirteen patients also received systemic chemotherapy in addition to some form of local therapy. The median survival for the entire group was 8 weeks (range 4 days to 18 months). Even those who initially responded to local therapy relapsed in the central nervous system (CNS) or succumbed to systemic disease. Five of six patients in whom CNS disease was the presenting feature survived 4 weeks or less. Conclusions: Leptomeningeal involvement is a rare and fatal complication of multiple myeloma with a short survival despite aggressive intrathecal and systemic chemotherapy and radiation therapy.

A case of meningeal myeloma presenting as obstructive hydrocephalus--a therapeutic challenge

Meningeal involvement in myeloma is a rare though recognised complication, and previous treatment strategies have included radiotherapy, intra-thecal and systemic chemotherapy to which there is almost universally a poor response. We report a case of a 60-year-old lady in serological remission with IgG lambda myeloma, presenting with obstructive hydrocephalus due to meningeal infiltration treated with neurosurgical decompression. Such presentation and the treatment strategies are previously unreported, though in view of the ultimate resistance to treatment the prognosis remains poor.

Cerebral and meningeal multiple myeloma after autologous stem cell transplantation. A case report and review of the literature

Meningeal involvement of multiple myeloma is a very rare complication. Defining meningeal myelomatosis (MeM) as the presence of plasma cells in the cerebrospinal fluid in a patient with multiple myeloma, we have found 53 previously reported cases in the literature, where the diagnosis MeM has been made while the patient was alive. Using Kaplan Meier statistics we have found the median survival, from the time of diagnosis of MeM, to be 1.5 months. We report a case with MeM and possible cerebral myeloma shortly after autologous stem cell transplantation, and compare it with earlier published cases.

[Neuromeningeal sites of multiple myeloma: 3 cases and review of the literature]

Neurologic manifestations are not unusual in multiple myeloma. Conversely meningeal and cerebral involvement have been very rarely reported. We report here on three patients with multiple myeloma and meningeal or cerebral involvement (two of them with autopsy study): one case of cerebellar involvement associated with secondary plasma cell leukemia and two cases of meningeal involvement. We reviewed the characteristics of 20 cases of meningeal involvement with demonstration of plasma cells at cerebrospinal fluid analysis (18 previously reported cases and our two patients). Meningeal involvement occurs in patients with initially stage III multiple myeloma in 85% of cases and is associated with the occurrence of plasma cell leukemia in 20% of cases. The most frequent neurologic signs are: confusion (60%), altered consciousness (25%), gait disorder (25%), cranial nerve palsy (25%). Meningismus is rarely present. Diagnosis is based on cerebrospinal fluid analysis after lumbar puncture which should be made after cranial magnetic resonance imaging. The diagnosis of intra-cranial haemorrhage and infectious meningitis have to be cautiously ruled out. Despite treatments (systemic and/or intrathecal chemotherapy, radiation therapy), prognosis is very poor: mean time of survival after the occurrence of neurologic signs is about 2 months.

Hyperammonaemic encephalopathy as the presenting feature of IgD multiple myeloma

We observed a case of hyperammonaemic encephalopathy in a patient without liver dysfunction which revealed meningeal involvement of IgD multiple myeloma. We have reviewed briefly the hyperammonaemic syndrome and we believe that this diagnosis has to be considered in differential diagnosis of encephalopathies in patients with multiple myeloma.

Leptomeningeal myelomatosis presenting with mental status changes and other neurologic findings

BACKGROUND

Leptomeningeal myelomatosis is a rare complication of multiple myeloma.

METHODS

The authors identified and studied three patients with leptomeningeal myelomatosis and reviewed previous case reports of this condition.

RESULTS

The patients described here had intermittent abnormalities in mental status or cranial nerve and brain stem abnormalities. Two of the patients responded dramatically, though transiently, to treatment. In one patient, the clinical findings correlated with lesions visualized by gadolinium-enhanced magnetic resonance imaging.

CONCLUSIONS

These patients are typical of those reported previously. Patients with leptomeningeal myelomatosis often have a good response to treatment initially, but long-term survival is rare.

Meningeal involvement in Bence Jones multiple myeloma

A case of Bence Jones kappa multiple myeloma with meningeal involvement in a 64-year-old woman is presented. Three years after the diagnosis of multiple myeloma, gait disturbances developed followed by visual disorders and impaired consciousness. A lumbar puncture revealed numerous atypical plasma cells in the cerebrospinal fluid. Craniospinal irradiation and intrathecal injections of methotrexate, cytarabine, and prednisolone were effective for a short period. At autopsy, the leptomeninges were infiltrated diffusely with atypical plasma cells. A review of the literature showed that multiple myeloma with meningeal involvement is accompanied frequently by circulating atypical plasma cells or plasma cell leukemia. Meningeal involvement is a rare complication and shows poor prognosis in cases of multiple myeloma.

Meningeal infiltration by non-myelomatous IgD-secreting plasma cell dyscrasias

Two cases of meningeal invasion by non-myelomatous plasma cell dyscrasias--a plasma cell leukaemia and an extramedullary plasmacytoma--are described. Both were secretors of IgD paraprotein and both were diagnosed in life, characteristics which we have not found in any other published case of plasma cell leptomeningitis. Analysis of our patients and of another 25 cases suggests as predisposing factors of meningeal invasion the male sex, presentation in the form of plasma cell leukaemia, presence of the IgD paraprotein and tumoral involvement of pleura, lung, pericardium and testicles. Aggressive treatment of this neurological complication controlled the meningeal disorder in some cases. However, the majority died of disseminated disease in spite of systemic chemotherapy. Until an effective treatment can be found, able to maintain remission or cure the systemic disease, prophylaxis of the central nervous system in plasma cell dyscrasias does not appear to be advisable.

Leptomeningeal plasmacytosis. Case report and considerations on treatment

We describe a 68-year-old patient with a plasma cell leukaemia in haematological remission presenting with massive intracranial leptomeningeal plasmocytic infiltration (LPI) and hydrocephalus. He was treated with skull irradiation and a combination of intraventricular and lumbar intrathecal therapy with methotrexate. Neurologic improvement and clearance of plasma cells from the cerebrospinal fluid was reached after 2 weeks of treatment but prolonged follow-up was interrupted by a lethal gastro-intestinal haemorrhage, 6 weeks after starting the therapy. From previously reported cases it is known that LPI almost always occurs in either high-grade plasmocytomas or plasma cell leukaemia. These data suggest that therapy of LPI should be the same as in other leukaemias with leptomeningeal infiltration.

Cranial nerve palsy as the presenting feature of secondary plasma cell leukemia

A patient with IgA lambda multiple myeloma (MM) developed plasma cell leukemia (PCL), presenting as oculomotor nerve palsy. The cerebrospinal fluid (CSF) contained plasma cells, which double stained with fluoresceinated anti-IgA and anti-lambda antisera. The palsy was most probably due to meningeal myelomatosis. The neurologic disorder appeared to be refractory to the therapy used, although plasma cells disappeared from the peripheral blood. Secondary plasma cell leukemia is a rare complication of MM, usually occurring in the terminal stage of the disease. Those patients may be eligible for central nervous system (CNS) prophylaxis, as is commonly performed in patients with other types of leukemia.

Partial response of meningeal myeloma to craniospinal radiotherapy

Concomitant occurrence of meningeal involvement and thoracic plasmacytoma was observed in a patient with IgA lambda myeloma. Cerebrospinal fluid analysis revealed IgA-lambda paraprotein and pathological plasma cells. CT scan of the chest and lumbar myelogram excluded spinal cord compression. The patient partially responded to craniospinal irradiation but succumbed to rapidly progressive myeloma 20 weeks following diagnosis of meningeal involvement.

Peripheral neuropathy in IgD myeloma. Cerebrospinal fluid paraprotein analysis in three cases

High resolution polyacrylamide gel isoelectric focusing (IEF), followed by direct immunofixation with anti-delta chains monospecific antibodies, were used to detect and identify IgD paraprotein in the cerebrospinal fluid (CSF) of 3 patients affected by IgD myeloma. Two of these patients presented a paraproteinemic neuropathy. Blood-brain barrier damage was investigated by means of CSF/serum albumin ratio. IgG index and CSF and serum IgD/albumin ratio were also evaluated. An intrathecal origin of the IgD paraprotein was excluded. The correlation between the presence of the paraprotein in the CSF and the possible neurological involvement was also examined.

IgDK multiple myeloma presenting as unilateral proptosis

A 72-year-old woman presented with painful proptosis of the right eye and a large destructive tumour of the middle cranial fossa. A diagnosis of IgDK multiple myeloma was made, based on histopathologic and immunologic studies of the biopsy. Biochemistry and bone marrow examination further confirmed the myeloma as IgDK type. The clinical, radiological, and pathological findings are presented. The patient was treated with radiotherapy with satisfactory results.

[Cerebrospinal fluid in benign and malignant monoclonal dysglobulinemias]

The authors compared 9 cases of myeloma and 2 cases of Waldenström's disease with 10 cases of benign monoclonal gammapathies. None of the patients (except one) had neurological involvement; one patient hab diabetes. The study was focused on the immunoglobulins and proteins in the CSF. The following observations were made: - The CSF protein was raised in 8 out of the 11 malignant gammopathies and in 5 out of the 10 benign gammopathies; - An identical monoclonal protein was found in the CSF and serum in all the cases of malignant gammopathies. In the cases considered to be benign, the results were less concordant: one IgM lymphoma had normal CSF; three IgG dysglobulinemias had different immunoglobulins proteins in their CSF: - The mean CSF immunoglobulin level was much higher in the myeloma patients than in the benign gammopathies; - A number of findings suggest intrathecal secretion (at least in the malignant gammopathies). This is also true in a good number of the benign gammopathy cases. Direct tumoural invasion of the CSF may be more common than generally supposed. However, the study of CSF immunoglobulins alone does not establish the diagnosis of malignant dysglobulinemia. Nevertheless, the authors consider that the finding of intrathecal secretion of immunoglobulin, especially in patients with a discordance in FAB and FC fractions, should lead to a closer follow-up of these patients.

Multiple cranial nerve palsies as the presenting feature of meningeal myelomatosis

The case of a 69-year-old man with IgGK myeloma in whom meningeal myelomatosis with multiple cranial nerve palsies developed, is reported. Review of previously reported cases of clinically apparent meningeal myelomatosis indicates this rare complication frequently presents with cranial nerve palsies; currently available treatment is ineffective.