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Traub R, Qarni T, Cohen AD, Karam C. Paraproteinemic neuropathies. Muscle Nerve 2024; 70:173-179. [PMID: 38816958 DOI: 10.1002/mus.28164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/14/2024] [Accepted: 04/27/2024] [Indexed: 06/01/2024]
Abstract
The diagnostic evaluation of a peripheral neuropathy includes testing for the presence of monoclonal gammopathy, which can be found in about 10% of patients with peripheral neuropathy. Our role, as physicians, is to determine whether the neuropathy is directly related to the gammopathy or whether the co-occurrence of these two disorders is purely coincidental. The evaluating physician needs to be familiar with the different types of neuropathies associated with monoclonal gammopathies, their clinical and electrodiagnostic characteristics, and their appropriate diagnostic evaluation and management. Testing for monoclonal protein disorders includes serum protein electrophoresis (SPEP) and immunofixation of blood, and in some cases of urine, as well as measurement of free light chains and quantitative immunoglobulins. Specific antibody testing is directed by paraprotein type and neuropathy phenotype. Patients with abnormal free light chains in association with sensory and autonomic neuropathy should be evaluated for AL amyloidosis. When a lambda monoclonal protein is identified together with a clinical phenotype of chronic inflammatory demyelinating neuropathy (CIDP), a diagnosis of polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, skin changes (POEMS) syndrome should be considered. Patients with IgM paraprotein associated neuropathy should be assessed for distal acquired demyelinating sensorimotor (DADS) neuropathy, with or without anti myelin associated glycoprotein (MAG) antibody or CANOMAD syndrome. In many cases, a monoclonal gammopathy of uncertain significance (MGUS) is incidental and unrelated to the neuropathy. Collaboration with oncology is critical in evaluating patients with monoclonal proteins to assess for underlying plasma cell neoplasms or B cell lymphomas.
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Affiliation(s)
- Rebecca Traub
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Taha Qarni
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adam D Cohen
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Amyloidosis Program, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chafic Karam
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Amyloidosis Program, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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2
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Gonçalves TAP, Donadel CD, Frezatti RSS, Garibaldi PMM, Calado RT, Marques Junior W, Tomaselli PJ. Monoclonal gammopathy-associated peripheral neuropathies: Uncovering pearls and challenges. J Peripher Nerv Syst 2024; 29:161-172. [PMID: 38873841 DOI: 10.1111/jns.12638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/26/2024] [Accepted: 05/28/2024] [Indexed: 06/15/2024]
Abstract
Monoclonal gammopathy-related peripheral neuropathies encompass a spectrum of clinical presentations in which the monoclonal protein directly damages the tissues, including the peripheral nervous system. Given the prevalence of both peripheral neuropathy and monoclonal gammopathy in the general population, these conditions may overlap in clinical practice, posing a challenge for clinicians in determining causality. Therefore, a comprehensive understanding of primary clinical syndromes and their neurophysiological patterns is of great importance for accurate differential diagnoses and effective treatment strategies. In this article, we examine the main forms of monoclonal gammopathies that affect the peripheral nerve. We explore the clinical and electrophysiological aspects and their correlation with each syndrome's corresponding monoclonal protein type. This knowledge is essential for healthcare professionals to diagnose better and manage patients presenting with monoclonal gammopathy-related peripheral nervous system involvement.
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Affiliation(s)
- Trajano Aguiar Pires Gonçalves
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Camila Derminio Donadel
- Department of Medical Imaging, Hematology, and Oncology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | | | - Pedro Manoel Marques Garibaldi
- Department of Medical Imaging, Hematology, and Oncology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Rodrigo T Calado
- Department of Medical Imaging, Hematology, and Oncology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Wilson Marques Junior
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Pedro José Tomaselli
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
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3
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Belkhribchia MR, Baroudi Z, Ajrinija A, Ikane I. Unusual Types of Plasma Cell Dyscrasias Associated With HIV: Polyneuropathy, Organomegaly, Endocrinopathy, M-protein, and Skin Changes (POEMS) Syndrome. Cureus 2024; 16:e62820. [PMID: 38912072 PMCID: PMC11191377 DOI: 10.7759/cureus.62820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2024] [Indexed: 06/25/2024] Open
Abstract
Polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes (POEMS) syndrome is a multisystem paraneoplastic disorder due to an underlying plasma cell neoplasm, and its occurrence among HIV patients is extremely rare. The diagnosis of POEMS syndrome can be challenging in this context, particularly if its disabling polyneuropathy is misdiagnosed as neuropathy related to HIV. Herein, we report the case of a female patient with treated HIV who later developed POEMS syndrome. After a misdiagnosis of chronic inflammatory demyelinating polyneuropathy related to HIV and unsuccessful corticosteroids and cyclophosphamide therapies, the correct diagnosis of POEMS syndrome was made. The patient achieved significant hematological and neurological improvement after six cycles of lenalidomide. Autologous stem cell transplantation was then scheduled to prevent eventual relapses.
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Affiliation(s)
| | - Zaineb Baroudi
- Department of Radiology, Hassan II Regional Hospital, Dakhla, MAR
| | | | - Itab Ikane
- Department of General Practice, Hassan II Regional Hospital, Dakhla, MAR
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4
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Tsunoda S, Harada T, Kikushige Y, Kishimoto T, Yoshizaki K. Immunology and targeted therapy in Castleman disease. Expert Rev Clin Immunol 2024:1-12. [PMID: 38785062 DOI: 10.1080/1744666x.2024.2357689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION Castleman disease (CD) is a benign lymphoproliferative disease causing severe systemic inflammation. Interleukin-6 (IL-6) is a major pathogenesis of multicentric CD (MCD), but only 30-60% of patients respond to IL-6 inhibitors. Novel agents for IL-6 inhibitor-refractory cases are needed. Clinical data and samples are being collected on a large scale and the clinical, pathological, and pathogenetic aspects are being elucidated. AREAS COVERED The pathological and clinical classification of CD is outlined. Focusing on idiopathic MCD (iMCD), this review identifies therapeutic targets and summarizes currently recommended drugs and promising therapeutic candidates. EXPERT OPINION The pathogenesis of MCD has been implicated in the activation of the Janus kinase (JAK)-transcriptional signaling activator (STAT) 3 pathway and the phosphatidylinositol 3-kinase (PI3K)/Akt/mechanical target of rapamycin (mTOR) signaling pathway. iMCD-TAFRO (thrombocytopenia, anasarca, fever/elevated CRP, reticulin myelofibrosis/renal dysfunction, organ enlargement) is resistant to IL-6 inhibitors, and cyclosporine and mTOR inhibitors are sometimes effective. JAK inhibitors and mTOR inhibitors may be therapeutic agents for iMCD. Recently, we have shown that peripheral helper T (Tph) cell abnormalities are at the core of iMCD pathogenesis. Therapies targeting chemokine (C-X-C motif) ligand 13 (CXCL13) produced by Tph cells and blocking the Tph-CXCL13-B cell pathway may satisfy unmet need in refractory cases.
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Affiliation(s)
- Shinichiro Tsunoda
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Sumitomo Hospital, Osaka, Japan
| | - Takuya Harada
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medicine, Fukuoka, Japan
- Department of Hematology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Yoshikane Kikushige
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medicine, Fukuoka, Japan
- Center for Cellular and Molecular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Tadamitsu Kishimoto
- Laboratory of Immune Regulation, WPI Immunology Frontier Research Center, Osaka University, Osaka, Japan
| | - Kazuyuki Yoshizaki
- The Institute of Scientific and Industrial Research, SANKEN, Osaka University, Osaka, Japan
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5
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Ishii A, Tsukamoto S, Mimura N, Miyamoto-Nagai Y, Isshiki Y, Matsui S, Nakao S, Shibamiya A, Hino Y, Kayamori K, Oshima-Hasegawa N, Muto T, Takeda Y, Suichi T, Misawa S, Ohwada C, Yokote K, Kuwabara S, Nakaseko C, Takamatsu H, Sakaida E. Detection of clonal plasma cells in POEMS syndrome using multiparameter flow cytometry. Sci Rep 2024; 14:10362. [PMID: 38710832 DOI: 10.1038/s41598-024-61034-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/30/2024] [Indexed: 05/08/2024] Open
Abstract
POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein [M-protein], and skin changes) is a rare systemic disorder characterized by various symptoms caused by underlying plasma cell (PC) dyscrasia. Detection of monoclonal PCs is mandatory for the diagnosis of POEMS syndrome; however, the usefulness of EuroFlow-based next-generation flow cytometry (EuroFlow-NGF) in POEMS syndrome for detecting monoclonal PCs in bone marrow (BM) and the gating strategy suitable for flow cytometry study of POEMS syndrome remain unknown. We employed EuroFlow-NGF-based single-tube eight-color multiparameter flow cytometry (MM-flow) and established a new gating strategy (POEMS-flow) to detect the monoclonal PCs in POEMS syndrome, gating CD38 broadly from dim to bright and CD45 narrowly from negative to dim compared to MM-flow. MM-flow detected monoclonal PCs in 9/25 (36.0%) cases, including 2/2 immunofixation electrophoresis (IFE)-negative cases (100%). However, POEMS-flow detected monoclonal PCs in 18/25 cases (72.0%), including 2/2 IFE-negative cases (100%). POEMS-flow detected monoclonal PCs with immunophenotypes of CD19- in 17/18 (94.4%). In six cases where post-treatment samples were available, the size of the clones was significantly reduced after the treatment (P = 0.031). POEMS-flow can enhance the identification rate of monoclonal PCs in POEMS syndrome and become a valuable tool for the diagnosis of POEMS syndrome.
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Affiliation(s)
- Arata Ishii
- Department of Hematology, Chiba University Hospital, Chiba, Japan
- Department of Endocrinology, Hematology, and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shokichi Tsukamoto
- Department of Hematology, Chiba University Hospital, Chiba, Japan.
- Department of Endocrinology, Hematology, and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Naoya Mimura
- Department of Hematology, Chiba University Hospital, Chiba, Japan
- Department of Transfusion Medicine and Cell Therapy, Chiba University Hospital, Chiba, Japan
| | | | - Yusuke Isshiki
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | | | - Sanshiro Nakao
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | - Asuka Shibamiya
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | - Yutaro Hino
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | - Kensuke Kayamori
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | | | - Tomoya Muto
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | - Yusuke Takeda
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | - Tomoki Suichi
- Department of Neurology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Sonoko Misawa
- Department of Neurology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Chikako Ohwada
- Department of Hematology, Chiba University Hospital, Chiba, Japan
- Department of Hematology, International University of Health and Welfare, Narita, Japan
| | - Koutaro Yokote
- Department of Endocrinology, Hematology, and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Chiaki Nakaseko
- Department of Hematology, International University of Health and Welfare, Narita, Japan
| | - Hiroyuki Takamatsu
- Department of Hematology, Institute of Medical, Pharmaceutical and Health Sciences, Faculty of Medicine, Kanazawa University, Kanazawa, Japan
| | - Emiko Sakaida
- Department of Hematology, Chiba University Hospital, Chiba, Japan
- Department of Endocrinology, Hematology, and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Transfusion Medicine and Cell Therapy, Chiba University Hospital, Chiba, Japan
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6
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Rodolfi S, Della-Torre E, Bongiovanni L, Mehta P, Fajgenbaum DC, Selmi C. Lymphadenopathy in the rheumatology practice: a pragmatic approach. Rheumatology (Oxford) 2024; 63:1484-1493. [PMID: 38109670 PMCID: PMC11147542 DOI: 10.1093/rheumatology/kead644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/31/2023] [Accepted: 11/05/2023] [Indexed: 12/20/2023] Open
Abstract
Lymphadenopathy is a common clinical finding and diagnostic challenge within general medicine and rheumatology practice. It may represent a primary manifestation of an underlying immune-mediated disease or indicate an infectious or neoplastic complication requiring differing management. Evaluating lymphadenopathy is of particular relevance in rheumatology, given that lymph node enlargement is a common finding within the clinical spectrum of several well-known rheumatologic disorders including RA, SLE and SS. In addition, lymphadenopathy represents a hallmark manifestation of rare immunological diseases such as Castleman disease and IgG4-related disease that must be considered in the differential diagnosis because effective targeted treatments can now impact the prognosis of these conditions. In this review we present an overview of the clinical significance of lymphadenopathy in common and rare rheumatologic diseases and propose a practical approach to lymphadenopathy in the rheumatology practice. Differential diagnosis of Castleman disease and therapeutic options for this condition of increasing rheumatologic interest will be discussed in detail.
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Affiliation(s)
- Stefano Rodolfi
- Department of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Emanuel Della-Torre
- Università Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), Milan, Italy
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lucia Bongiovanni
- Università Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Haematopathology Diagnostic Area, Unit of Pathology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Puja Mehta
- Division of Medicine, University College, Centre for Inflammation and Tissue Repair, UCL Respiratory, London
- Department of Rheumatology, University College London Hospital (UCLH), London, UK
| | - David C Fajgenbaum
- Department of Medicine, Division of Translational Medicine and Human Genetics, Center for Cytokine Storm Treatment and Laboratory, Philadelphia, PA, USA
| | - Carlo Selmi
- Department of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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7
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Rodriguez-Domínguez V, Hernández-García BJ, Abenza-Abildúa MJ. Hydrocephalus associated with POEMS syndrome. Med Clin (Barc) 2024:S0025-7753(24)00205-7. [PMID: 38697895 DOI: 10.1016/j.medcli.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/13/2024] [Accepted: 02/14/2024] [Indexed: 05/05/2024]
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8
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King HL, Benedetti GB, Keller JJ, DeLoughery TG, Shatzel JJ, Martens KL. Dermatologic manifestations of hematologic disorders. Ann Hematol 2024:10.1007/s00277-024-05761-5. [PMID: 38662204 DOI: 10.1007/s00277-024-05761-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 04/14/2024] [Indexed: 04/26/2024]
Abstract
Distinguishing key morphologic features and understanding the pathophysiology of common cutaneous manifestations of hematologic disorders is essential to ensure prompt and appropriate treatment. In fact, classic cutaneous signs may provide the first clue to the diagnosis of an underlying hematologic disease. Disorders of coagulation, vascular abnormalities, or cutaneous infiltration and deposition are responsible for the underlying pathophysiology of cutaneous manifestations in the majority of cases. Hematologists often feel ill-equipped in identifying morphologic changes in the skin. Thus, the purpose of this review is to provide a comprehensive overview of classic cutaneous manifestations and diagnostic considerations of the associated hematologic conditions. Though there is a specific focus on non-malignant disorders, those straddling the spectrum of malignancy are also discussed. In many disease states, the skin may serve as an important marker of an emerging hematologic disorder, so close collaboration and multidisciplinary input remain essential to provide optimal and timely care for these patients.
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Affiliation(s)
- Hannah L King
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | | | - Jesse J Keller
- Department of Dermatology, Oregon Health & Science University, Portland, OR, USA
| | - Thomas G DeLoughery
- Division of Hematology and Medical Oncology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road Mail Code: OC14HO, 97239, Portland, OR, USA
| | - Joseph J Shatzel
- Division of Hematology and Medical Oncology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road Mail Code: OC14HO, 97239, Portland, OR, USA
| | - Kylee L Martens
- Division of Hematology and Medical Oncology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road Mail Code: OC14HO, 97239, Portland, OR, USA.
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9
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Rodriguez Merino L, Pomares AA, Arce JR, Montes-Moreno S. From Castleman disease histopathological features to idiopathic multicentric Castleman disease: a multiparametric approach to exclude potential iMCD histopathological mimickers. J Clin Pathol 2024; 77:318-323. [PMID: 36690434 DOI: 10.1136/jcp-2022-208696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/12/2023] [Indexed: 01/24/2023]
Abstract
AIMS International consensus diagnostic criteria for idiopathic multicentric Castleman disease (iMCD) includes lymph node Castleman disease (CD) histopathological features as major criteria. Our aim was to apply those criteria in a series of 42 cases with CD to find differences among unicentric CD, iMCD, HHV-8+multicentric CD (HHV-8+MCD) and POEMS/plasma cell neoplasia (PCN)-associated CD. METHODS Available clinical and laboratory criteria were collected. Histopathological features (germinal centre hyperplasia/regression, plasmacytosis, hypervascularity and follicular dendritic cell (FDC) prominence) were graded and immunohistochemistry with antibodies against CD20, CD3, CD138, HHV-8, Ig isotype (IgG, IgG4, IgA, IgM, IgD), kappa, lambda was performed in all cases. RESULTS Fourteen cases had hyaline-vascular type unicentric CD, 15 were HHV-8+MCD, 7 cases PCN/POEMS-associated CD and 5 cases were iMCD. One case was consistent with systemic lupus erythematosus (SLE) lymphadenopathy. Differences in grading of the CD-associated histopathological features showed that FDC proliferation was prominent in unicentric CD, hypervascularity was increased in HHV-8 positive MCD and germinal centre hyperplasia was restricted to iMCD cases and SLE. Monotypic plasma cells were readily identifiable in the lymph node biopsies in 43% of PCN/POEMS-associated CD. All three cases had lambda light chain restriction with IgA (two cases) and IgG (one case) isotypes. CONCLUSIONS HHV-8+ MCD and PCN/POEMS-related CD are the major mimickers of iMCD in lymph node biopsies. Grading of the five histopathological features for CD might be useful to, in conjunction with complete ancillary testing, suggest for specific disease entities.
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Affiliation(s)
| | - Aitana Avendaño Pomares
- Translational Hematopathology/IDIVAL, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - Jose Revert Arce
- Pathology Department, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - Santiago Montes-Moreno
- Anatomic Pathology, Hospital Universitario Marques de Valdecilla, Universidad de Cantabria (UNICAN), Santander, Spain
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10
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Li ZY, Chen JJ, Lu FY, Gan MF, Tung TH, Hong D. Non-POEMS osteosclerotic multiple myeloma: Clinical characteristics and differential diagnosis. J Bone Oncol 2024; 45:100595. [PMID: 38572352 PMCID: PMC10987900 DOI: 10.1016/j.jbo.2024.100595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/15/2024] [Accepted: 03/18/2024] [Indexed: 04/05/2024] Open
Abstract
Osteosclerosis in multiple myeloma (MM) is typically associated with rare POEMS syndrome, characterized by polyneuropathy (P), organomegaly (O), endocrinopathy (E), M-protein (M), and skin changes (S). However, osteosclerosis in multiple myeloma (MM) without POEMS syndrome, defined as non-POEMS Osteosclerotic MM, is exceedingly rare. We report a 70-year-old man with rib pain, remarkably high bone mineral density and diffuse osteosclerosis. The diagnosis of non-POEMS osteosclerotic MM was confirmed by biopsy and aspiration of bone marrow through surgery. A literature review spanning from 1990 identified 12 cases of similar non-POEMS osteosclerotic MM, including 5 males and 7 females with a mean age of 59.7 ± 10.6 years. The non-POEMS osteosclerotic MM can be divided into two subtypes, the osteosclerotic lesion subtype and the diffuse osteosclerosis subtype. Absence of polyneuropathy and organomegaly are the main factors that differentiate non-POEMS osteosclerotic MM from POEMS. A hyperactive osteoblastic process might be the etiology of diffuse osteosclerosis. Further research is needed to understand its etiology and pathophysiology.
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Affiliation(s)
- Zi-Yan Li
- Department of Bone Disease, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Jiang-Jie Chen
- Department of Bone Disease, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Fang-Ying Lu
- Department of Bone Disease, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Mei-Fu Gan
- Department of Pathology, Taizhou Hospital affiliated to Wenzhou Medical University, Linhai, China
| | - Tao-Hsin Tung
- Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Dun Hong
- Department of Bone Disease, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
- Bone Metabolism and Development Research Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
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11
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Aderhold W, Lenz B, Hübner MP, Schaefer HE, Gaertner FC, Heine A, Gütgemann I. Intramedullary leukocytoclastic vasculitis and neutrophil extracellular trap (NET) formation in POEMS syndrome. Ann Hematol 2024; 103:1415-1417. [PMID: 38436672 PMCID: PMC10940367 DOI: 10.1007/s00277-024-05651-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/31/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Wiebke Aderhold
- Institute of Pathology, University Hospital Bonn, Bonn, Germany
| | - Benjamin Lenz
- Institute for Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany
| | - Marc P Hübner
- Institute for Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany
- German Center for Infection Research (DZIF), Partner Site, Bonn-Cologne, Bonn, Germany
| | | | | | - Annkristin Heine
- Medical Clinic III for Hematology, Oncology, Rheumatology and Stem Cell Transplantation, University Hospital Bonn, Bonn, Germany
| | - Ines Gütgemann
- Institute of Pathology, University Hospital Bonn, Bonn, Germany.
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12
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Knapp S, Bolko L, Servettaz A, Didier K. [[Eosinophilic fasciitis: From pathophysiology to therapeutics]]. Rev Med Interne 2024:S0248-8663(24)00086-9. [PMID: 38519306 DOI: 10.1016/j.revmed.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/27/2024] [Accepted: 03/07/2024] [Indexed: 03/24/2024]
Abstract
Eosinophilic fasciitis (EF) is a rare connective tissue disorder characterized by painful edema and induration of the limbs and trunk, likely associated with hypereosinophilia and hypergammaglobulinemia. EF causes arthralgia and range of motion limitation, leading to significant functional impairment and poor quality of life. Since its description by Shulman in 1974, over 300 cases have been reported. We present here a review of the latest diagnostic, pathophysiological and therapeutic developments in this disease. Magnetic resonance imaging appears useful to guide diagnosis and biopsy. Diagnosis is based on a deep skin biopsy involving the fascia, which will reveal edema, sclerofibrosis of the muscular fascia and subcutaneous tissue, and an inflammatory infiltrate sometimes composed of eosinophilic polynuclear cells. EF may occur in patients treated with immune checkpoint inhibitors and the diagnosis should be raised in case of cutaneous sclerosis in these patients. The pathophysiology of the disease remains poorly understood, and its management lacks randomized, controlled, blinded trials. First-line treatment consists in oral corticosteroid therapy, sometimes combined with an immunosuppressant, mainly methotrexate. A better understanding of the pathophysiology has opened new therapeutic perspectives and clarified the role of targeted therapies in the management of EF, such as interleukin-6 inhibitors, whose efficacy has been reported in several cases.
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Affiliation(s)
- S Knapp
- Service de médecine interne, maladie infectieuse et immunologie clinique, hôpital Robert-Debré, CHU de Reims, rue du Général-Kœnig, 51092 Reims cedex, France
| | - L Bolko
- Service de rhumatologie, hôpital Maison Blanche, CHU de Reims, Reims, France
| | - A Servettaz
- Service de médecine interne, maladie infectieuse et immunologie clinique, hôpital Robert-Debré, CHU de Reims, rue du Général-Kœnig, 51092 Reims cedex, France; EA 7509 IRMAIC, université de Reims Champagne-Ardenne, Reims, France
| | - K Didier
- Service de médecine interne, maladie infectieuse et immunologie clinique, hôpital Robert-Debré, CHU de Reims, rue du Général-Kœnig, 51092 Reims cedex, France; EA 7509 IRMAIC, université de Reims Champagne-Ardenne, Reims, France.
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Magalhães ARG, Santos MB, Almeida PH, Carvalho AMF, Exposito BT. Human Herpesvirus 8-Positive Multicentric Castleman Disease in an Immunocompetent Patient: A Diagnostic Challenge. Cureus 2024; 16:e56534. [PMID: 38646242 PMCID: PMC11027444 DOI: 10.7759/cureus.56534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 04/23/2024] Open
Abstract
We present a clinical case of a 79-year-old male admitted to inpatient care for longstanding asthenia and respiratory symptoms. Associated features were polyserositis, multiple enlarged lymphatic nodules, acute kidney injury, and heart failure. The patient's recent medical history revealed SARS-CoV-2 vaccination a week prior and an upper respiratory tract infection. The laboratory results from thoracentesis were compatible with a transudate, with no immunological stain. Epstein-Barr virus polymerase chain reaction (PCR) was positive. The thoracic, abdominal, and pelvic CT scans revealed multiple enlarged lymphatic nodules, worsening the pre-existent polyserositis and hepatosplenomegaly. The patient began to show signs of neurologic symptoms and deterioration of the global health status. An enlarged lymphatic nodule was excised and the pathology showed human herpesvirus 8 multicentric Castleman disease. The disease evolved rapidly into hematological dysfunction and blood transfusions were necessary. Even though the patient was started on high-dose rituximab therapy combined with etoposide, the disease evolved into multiorgan dysfunction with a fatal outcome.
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Affiliation(s)
- Ana Rita G Magalhães
- Internal Medicine, Centro Hospitalar de Trás-os-Montes e Alto Douro, Chaves, PRT
| | - Marta B Santos
- Internal Medicine, Centro Hospitalar de Trás-os-Montes e Alto Douro, Chaves, PRT
| | - Pedro H Almeida
- Internal Medicine, Centro Hospitalar de Trás-os-Montes e Alto Douro, Chaves, PRT
| | - Ana Maria F Carvalho
- Internal Medicine, Centro Hospitalar de Trás-os-Montes e Alto Douro, Chaves, PRT
| | - Beatriz T Exposito
- Internal Medicine, Centro Hospitalar de Trás-os-Montes e Alto Douro, Chaves, PRT
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14
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Murina A, Allen A. Paraneoplastic Dermatoses and Cutaneous Metastases. Clin Geriatr Med 2024; 40:177-195. [PMID: 38000859 DOI: 10.1016/j.cger.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Paraneoplastic syndromes include a variety of cutaneous presentations that have an associated internal malignancy. Some syndromes have a strong correlation to specific internal malignancies, whereas others are associated with a multitude of tumors. There are many cutaneous manifestations that suggest hematologic disorders, which will be reviewed in detail. Cutaneous metastases are commonly from breast and lung cancers and can present as nodules, vascular lesions, eczematous dermatitis, or inflammatory lesions. The most common histologic presentation of cutaneous metastasis is that of a dermal-based or subcutaneous-based nodule with sparing of the epidermis. Determination of origin of tumor requires immunohistochemistry and clinical correlation.
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Affiliation(s)
- Andrea Murina
- Department of Dermatology, Tulane University School of Medicine, 1430 Tulane Avenue #8036, New Orleans, LA 70112, USA.
| | - Ashley Allen
- Department of Dermatology, Tulane University School of Medicine, 1430 Tulane Avenue #8036, New Orleans, LA 70112, USA
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15
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Li JR, Feng LY, Li JW, Liao Y, Liu FQ. Polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes syndrome with dilated cardiomyopathy: A case report. World J Clin Cases 2024; 12:601-606. [PMID: 38322456 PMCID: PMC10841945 DOI: 10.12998/wjcc.v12.i3.601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/16/2023] [Accepted: 01/04/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes (POEMS) syndrome is a rare paraneoplastic syndrome that encompass multiple systems. The most common clinical symptoms of POEMS syndrome are progressive sensorimotor polyneuropathy, organ enlargement, endocrine disorders, darkening skin, a monoclonal plasma cell proliferative disorder, and lymph node hyperplasia. The organomegaly consists of hepatosplenomegaly and/or lymphadenopathy; cases of cardiomyopathy are rare. Diagnoses are often delayed because of the atypical nature of the syndrome, exposing patients to possibly severe disability. Therefore, identifying atypical symptoms can improve the prognosis and quality of life among POEMS syndrome patients. CASE SUMMARY Herein, we report the case of a 59-year-old woman with POEMS syndrome that involved dilated cardiomyopathy. The patient presented to the hospital with complaints of shortness of breath and discomfort in the chest. The patient reported previous experiences of limb numbness. During hospitalization, the brain natriuretic peptide levels were 3504.0 pg/mL. Color doppler echocardiography showed an enlarged left side of the heart, along with ventricular wall hypokinesis and compromised functioning of the same side of the heart. Abdominal color ultrasonography revealed that the patient's spleen was enlarged. Observations from cardiac magnetic resonance imaging showed that the left side of the heart was enlarged. Slight myocardical fibrosis was also observed. Electromyography was described as a symmetric sensorimotor demyelinating polyneuropathy. Further immunoelectrophoresis of the serum showed the presence of a monoclonal IGA λ M protein. The vascular endothelial growth factor levels were 622.56 pg/mL. Flow cytometric and immunohistochemical staining of the bone marrow detected no monoclonal plasma cells. Finally, the patient was diagnosed with POEMS syndrome associated with dilated cardiomyopathy. The chest-related discomfort and the shortness of breath resolved after the administration of lenalidomide and dexamethasone. CONCLUSION When patients with cardiomyopathy have systemic manifestations such as numb limbs and darkening skin, the POEMS syndrome is the most possible diagnosis.
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Affiliation(s)
- Jia-Rong Li
- Department of General Medicine, Xiangtan Central Hospital, Xiangtan 411100, Hunan Province, China
| | - Lei-Yu Feng
- Department of General Medicine, Xiangtan Central Hospital, Xiangtan 411100, Hunan Province, China
| | - Jian-Wei Li
- Department of General Medicine, Xiangtan Central Hospital, Xiangtan 411100, Hunan Province, China
| | - Yu Liao
- Department of General Medicine, Xiangtan Central Hospital, Xiangtan 411100, Hunan Province, China
| | - Fei-Qi Liu
- Department of General Medicine, Xiangtan Central Hospital, Xiangtan 411100, Hunan Province, China
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16
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Shelly S, Dubey D, Mills JR, Klein CJ. Paraneoplastic neuropathies and peripheral nerve hyperexcitability disorders. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:239-273. [PMID: 38494281 DOI: 10.1016/b978-0-12-823912-4.00020-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Peripheral neuropathy is a common referral for patients to the neurologic clinics. Paraneoplastic neuropathies account for a small but high morbidity and mortality subgroup. Symptoms include weakness, sensory loss, sweating irregularity, blood pressure instability, severe constipation, and neuropathic pain. Neuropathy is the first presenting symptom of malignancy among many patients. The molecular and cellular oncogenic immune targets reside within cell bodies, axons, cytoplasms, or surface membranes of neural tissues. A more favorable immune treatment outcome occurs in those where the targets reside on the cell surface. Patients with antibodies binding cell surface antigens commonly have neural hyperexcitability with pain, cramps, fasciculations, and hyperhidrotic attacks (CASPR2, LGI1, and others). The antigenic targets are also commonly expressed in the central nervous system, with presenting symptoms being myelopathy, encephalopathy, and seizures with neuropathy, often masked. Pain and autonomic components typically relate to small nerve fiber involvement (nociceptive, adrenergic, enteric, and sudomotor), sometimes without nerve fiber loss but rather hyperexcitability. The specific antibodies discovered help direct cancer investigations. Among the primary axonal paraneoplastic neuropathies, pathognomonic clinical features do not exist, and testing for multiple antibodies simultaneously provides the best sensitivity in testing (AGNA1-SOX1; amphiphysin; ANNA-1-HU; ANNA-3-DACH1; CASPR2; CRMP5; LGI1; PCA2-MAP1B, and others). Performing confirmatory antibody testing using adjunct methods improves specificity. Antibody-mediated demyelinating paraneoplastic neuropathies are limited to MAG-IgM (IgM-MGUS, Waldenström's, and myeloma), with the others associated with cytokine elevations (VEGF, IL6) caused by osteosclerotic myeloma, plasmacytoma (POEMS), and rarely angiofollicular lymphoma (Castleman's). Paraneoplastic disorders have clinical overlap with other idiopathic antibody disorders, including IgG4 demyelinating nodopathies (NF155 and Contactin-1). This review summarizes the paraneoplastic neuropathies, including those with peripheral nerve hyperexcitability.
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Affiliation(s)
- Shahar Shelly
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Neurology, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Christopher J Klein
- Department of Neurology, Mayo Clinic, Rochester, MN, United States; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
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17
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Kang H, Hubbi ME. A Rare Cause of Chronic Diarrhea and Peripheral Neuropathy. Gastroenterology 2024; 166:e17-e19. [PMID: 37714363 DOI: 10.1053/j.gastro.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/10/2023] [Indexed: 09/17/2023]
Affiliation(s)
- Hansol Kang
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Maimon E Hubbi
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
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18
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Rashed HR, Niu Z, Dyck PJ, Dyck PJB, Mauermann ML, Berini SE, Dubey D, Mills JR, Staff NP, Wu Y, Spinner RE, Dasari S, Klein CJ. Nerve transcriptomes in autoimmune and genetic demyelinating neuropathies: Pathogenic pathway assessment of nerve demyelination. J Neuroimmunol 2023; 384:578220. [PMID: 37857228 DOI: 10.1016/j.jneuroim.2023.578220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/03/2023] [Accepted: 10/01/2023] [Indexed: 10/21/2023]
Abstract
The pathogenesis of autoimmune demyelinating neuropathies is poorly understood compared to inherited demyelinating forms. We performed whole transcriptome (RNA-Seq) using nerve biopsy tissues of patients with different autoimmune and inherited demyelinating neuropathies (CIDP n = 10, POEMS n = 18, DADS n = 3, CMT1 n = 3) versus healthy controls (n = 6). A limited number of differentially expressed genes compared to healthy controls were identified (POEMS = 125, DADS = 15, CMT = 14, CIDP = 5). Divergent pathogenic pathways including inflammatory, demyelinating and neurite regeneration such as with the triggering receptor expressed on myeloid cells (TREM1) part of the immunoglobulin superfamily and RhoGD1 are found. Shared and discordant pathogenic injury are discovered between autoimmune and inherited forms.
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Affiliation(s)
- Hebatallah R Rashed
- Department of Neurology, Mayo Clinic Foundation, Rochester, MN, United States of America
| | - Zhiyv Niu
- Department of Laboratory Medicine and Pathology, Rochester, MN, United States of America
| | - Peter J Dyck
- Department of Neurology, Mayo Clinic Foundation, Rochester, MN, United States of America
| | - P James B Dyck
- Department of Neurology, Mayo Clinic Foundation, Rochester, MN, United States of America
| | - Michelle L Mauermann
- Department of Neurology, Mayo Clinic Foundation, Rochester, MN, United States of America
| | - Sarah E Berini
- Department of Neurology, Mayo Clinic Foundation, Rochester, MN, United States of America
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic Foundation, Rochester, MN, United States of America; Department of Laboratory Medicine and Pathology, Rochester, MN, United States of America
| | - John R Mills
- Department of Laboratory Medicine and Pathology, Rochester, MN, United States of America
| | - Nathan P Staff
- Department of Neurology, Mayo Clinic Foundation, Rochester, MN, United States of America
| | - Yanhong Wu
- Department of Laboratory Medicine and Pathology, Rochester, MN, United States of America
| | - Robert E Spinner
- Department of Neurosurgery, Rochester, MN, United States of America
| | - Surendra Dasari
- Department of Quantitative Health Sciences, Mayo Clinic Foundation, Rochester, MN, United States of America
| | - Christopher J Klein
- Department of Neurology, Mayo Clinic Foundation, Rochester, MN, United States of America; Department of Laboratory Medicine and Pathology, Rochester, MN, United States of America.
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19
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Takeuchi H, Yamamoto Y, Miyahara J, Takeshima T, Ozaki A, Kawasaki T, Kawamura K, Oka N. Small vessel platelet thrombosis in the peripheral nerves in POEMS syndrome. Muscle Nerve 2023; 68:882-885. [PMID: 37837287 DOI: 10.1002/mus.27986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 09/22/2023] [Accepted: 09/29/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION/AIMS Vascular thrombosis is prevalent among patients with polyneuropathy, organomegaly, endocrinopathy M-protein, and skin changes (POEMS) syndrome. The endothelial cells in the endoneurium are often hypertrophied and the lumen is frequently occluded. Consequent local hypoxia may increase vascular endothelial growth factor (VEGF), which induces hypercoagulation and vascular permeability. METHODS This study presents two patients in the fifth decade of life, who had rare nerve biopsy findings of vascular occlusion mainly by platelets. Before the cases presented here, we encountered nine confirmed POEMS patients whose nerve biopsies did not show similar findings. RESULTS A small artery and a vein were occluded, but no atherosclerotic changes were observed. The endothelial cells that adhered to the packed platelets lost their junctions. DISCUSSION Platelet aggregation, degranulation, and ischemia may cause a loose endothelial barrier and leak proinflammatory cytokines, such as interleukin-12. This may increase production of VEGF and may cause nerve demyelination. Small vessel platelet thrombosis may contribute to the pathogenesis of this disorder.
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Affiliation(s)
- Hiroki Takeuchi
- Department of Neurology, NHO Minami-Kyoto Hospital, Kyoto, Japan
| | | | | | | | - Akihiko Ozaki
- Department of Neurology, Osaka Red Cross Hospital, Osaka, Japan
| | | | | | - Nobuyuki Oka
- Department of Neurology, NHO Minami-Kyoto Hospital, Kyoto, Japan
- Kyoto Konoe Rehabilitation Hospital, Kyoto, Japan
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20
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Haider SA, Iram S, Rashid AA, Manazar A, Javed H. POEMS (Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal Plasma Cell Disorder, and Skin Changes) Syndrome as a Sequela of Castleman Disease: A Case Report. Cureus 2023; 15:e49330. [PMID: 38143657 PMCID: PMC10748833 DOI: 10.7759/cureus.49330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2023] [Indexed: 12/26/2023] Open
Abstract
Polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, and skin changes (POEMS) syndrome is a rare multisystemic paraneoplastic disorder caused by an underlying plasma cell dyscrasia. Its diagnosis is based on the presence of two mandatory criteria and at least one major and one minor criterion. We report a case of a 52-year-old female patient who presented with complaints of acrocyanosis, night sweats, scaly skin, and swelling on the left side of the neck. She was a known case of hypothyroidism, antiphospholipid syndrome, and cerebral venous thrombosis, and had other comorbidities as well. She also exhibited weakness and paresthesia of the limbs and muscle wasting in the hands. All necessary examinations and investigations were performed and the patient was eventually diagnosed with POEMS syndrome. She underwent chemotherapy along with immunotherapy initially, but as the disease relapsed, she was referred for high-dose therapy (HDT) and autologous stem cell transplantation.
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Affiliation(s)
| | - Sadia Iram
- Medicine, Lahore Medical and Dental College, Lahore, PAK
| | | | - Anusha Manazar
- Medicine, University College of Medicine and Dentistry, Lahore, PAK
| | - Hamza Javed
- Medicine, University College of Medicine and Dentistry, Lahore, PAK
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21
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Sato H, Kanno A, Sato M, Endo A, Ito H, Ohara T, Shirota Y, Sumitomo K, Mori T, Furukawa K. Case Report: A case of TAFRO syndrome with severe and prolonged thrombocytopenia: diagnostic pitfalls. Front Immunol 2023; 14:1266187. [PMID: 37901232 PMCID: PMC10611515 DOI: 10.3389/fimmu.2023.1266187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/27/2023] [Indexed: 10/31/2023] Open
Abstract
Thrombocytopenia, anasarca, myelofibrosis, renal dysfunction, and organomegaly (TAFRO) syndrome is a rare condition with diverse clinical and pathological characteristics related to multi-organ damage. We report a case of TAFRO syndrome complicated by immune thrombocytopenia with prolonged fever and thrombocytopenia for several weeks. A 61-year-old man was transferred with sepsis caused by Enterococcus faecalis, and developed disseminated intravascular coagulation. Antibiotics treatment was initiated: however, low-grade fever and thrombocytopenia persisted despite the adequate antimicrobial treatment. Systemic edema, pleural effusion, and ascites had developed before hospitalization, and renal and liver function had deteriorated, resulting in progressive multi-organ damage. Prednisolone 40 mg/day was initiated based on the assumption of a condition in which excessive production of inflammatory cytokines would lead to systemic deterioration and fatal organ damage. Subsequently, the fever resolved, and renal function began to normalize. However, thrombocytopenia did not show much recovery trend after Helicobacter pylori eradication therapy and initiation of thrombopoietin receptor agonists. Bone marrow biopsy results showed normal bone marrow with no malignant findings. Alternatively, significant clinical signs met the diagnostic criteria for TAFRO syndrome, and a renal biopsy revealed thrombotic microangiopathy, which is also reasonable for renal involvement in TAFRO syndrome. The use of cyclosporine remarkably corrected the thrombocytopenia. We considered this a case of TAFRO syndrome that developed after sepsis with disseminated intravascular coagulation and performed the differential diagnosis of prolonged thrombocytopenia and excluded it. Although TAFRO syndrome is a unique disease concept, diagnostic criteria may consist of nonspecific elements such as generalized edema, thrombocytopenia, persistent fever, and elevated inflammatory response, and there are many differential conditions to exclude, requiring caution in diagnosing TAFRO syndrome.
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Affiliation(s)
- Hironori Sato
- Division of Geriatric and Community Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Atsuhiro Kanno
- Division of Geriatric and Community Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Minato Sato
- Division of Geriatric and Community Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Akari Endo
- Division of Nephrology and Endocrinology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Hiroki Ito
- Division of Nephrology and Endocrinology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Takahiro Ohara
- Division of Geriatric and Community Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Yuko Shirota
- Division of Hematology and Rheumatology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Kazuhiro Sumitomo
- Department of Community and General Medicine, Tohoku Medical and Pharmaceutical University, Wakabayashi Hospital, Sendai, Japan
| | - Takefumi Mori
- Division of Nephrology and Endocrinology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Katsutoshi Furukawa
- Division of Geriatric and Community Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
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22
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Zhang F, Wu Z, Sun S, Fu Y, Chen Y, Liu J. POEMS syndrome in the 21st century: A bibliometric analysis. Heliyon 2023; 9:e20612. [PMID: 37842561 PMCID: PMC10570589 DOI: 10.1016/j.heliyon.2023.e20612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/26/2023] [Accepted: 10/02/2023] [Indexed: 10/17/2023] Open
Abstract
Background POEMS syndrome is a rare and complex plasma cell disorder characterized by polyneuropathy, organomegaly, endocrinopathy, high M protein levels, and skin changes. Understanding of POEMS syndrome has advanced rapidly since the 21st century. This study aims to summarize and evaluate the research status of POEMS syndrome in the past 23 years through a bibliometric and visualization analysis, and identify research focuses and emerging hotspots for the future. Methods POEMS syndrome-related articles published between January 1, 2000, and March 8, 2023, were systematically retrieved from the Web of Science Core Collection. Data processing and visualization analysis were carried out using a combination of R software, HistCite, VOSviewer, and CiteSpace. Results Since entering the 21st century, 3677 authors from 1125 institutions in 68 countries/regions have published 830 original and review articles on POEMS syndrome in 408 journals so far, among which the USA, Japan, and China published the most articles, and Mayo Clinic, Udice French Research Universities, and Peking Union Medical College listed the top three most prolific institutions. However, collaborative research across countries and groups in the study of POEMS syndrome remain significantly limited. Angela Dispenzieri ranked first in POEMS syndrome research from every aspect of authors, producing the most papers and contributing the most-cited article, followed by Satoshi Kuwabara and Sonoko Misawa. Internal medicine was the most productive journal on POEMS syndrome. "endothelial growth factor" was the keyword with the highest occurrence except for "POEMS syndrome", and "bevacizumab", "lenalidomide", "dexamethasone", and "management" were recognized as emerging topics. Conclusion This study utilized bibliometric and visualization analysis to systematically summarize the research of POEMS syndrome in the first two decades of the 21st century, offering a data-based and objective perspective on the field of POEMS syndrome and guiding researchers in the identification of novel research directions.
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Affiliation(s)
- Fangrong Zhang
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, China
| | - Zhimin Wu
- Guiyang maternal and child health care hospital, Guiyang Children's Hospital, Guiyang, Guizhou, 550003, China
| | - Shanyi Sun
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Yunfeng Fu
- Department of Blood Transfusion, The Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, China
| | - Yi Chen
- Department of Breast and Thyroid Surgery, The Afflicted Cancer Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region, 830011, China
- The China-US (Henan) Hormel Cancer Institute, Zhengzhou, Henan, 450008, China
| | - Jing Liu
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, China
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23
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Beydoun SR, Darki L. Paraproteinemic Neuropathies. Continuum (Minneap Minn) 2023; 29:1492-1513. [PMID: 37851040 DOI: 10.1212/con.0000000000001294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE Coexistence of polyneuropathy and gammopathy is a common but potentially challenging situation in clinical practice. This article reviews the clinical, electrophysiologic, and hematologic phenotypes of the paraproteinemic neuropathies and the diagnostic and treatment strategies for each. LATEST DEVELOPMENTS Advances in our understanding of the underlying pathophysiology of various paraproteinemic neuropathies and their corresponding phenotypes have identified potential new therapeutic targets. Therapeutic strategies to diminish anti-myelin-associated glycoprotein (MAG) IgM antibodies have shown partial and inconsistent efficacy; however, antigen-specific immune therapy is being investigated as a novel treatment to remove the presumably pathogenic anti-MAG antibody. Advances in genetic and cell signaling studies have resulted in the approval of Bruton tyrosine kinase inhibitors for Waldenström macroglobulinemia. Monoclonal antibodies are being investigated for the treatment of light chain amyloidosis. ESSENTIAL POINTS Early recognition and treatment of underlying plasma cell disorders improves clinical outcomes in patients with paraproteinemic neuropathy. Despite significant progress, our knowledge regarding underlying mechanisms for paraproteinemic neuropathy is still limited. Clinicians' awareness of clinical phenotypes, electrophysiologic hallmarks, and hematologic findings of the different paraproteinemic neuropathies is crucial to promptly identify and treat patients and to avert misdiagnosis. Multidisciplinary collaboration among specialists, including neurologists and hematologists, is paramount for the optimal treatment of these patients with overlapping conditions.
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Gable K. Chronic Immune-Mediated Demyelinating Neuropathies. Continuum (Minneap Minn) 2023; 29:1357-1377. [PMID: 37851034 DOI: 10.1212/con.0000000000001290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE This article is an overview of chronic demyelinating neuropathies and highlights the phenotypic categorization, diagnosis, and treatment of chronic immune-mediated neuropathies. The clinical and diagnostic characteristics of other chronic demyelinating neuropathies that are common mimics of immune-mediated neuropathies are also discussed. LATEST DEVELOPMENTS The underlying pathophysiology of chronic demyelinating neuropathies is heterogeneous, and components of both humoral and cellular immune responses are thought to play a role in the immune-mediated types of chronic demyelinating neuropathy. The role of the humoral response is highlighted with a specific focus on the relatively recent discovery of antibody-mediated antinodal and paranodal demyelinating neuropathies. Additionally, new diagnostic criteria for some of the chronic demyelinating neuropathies, as well as ways to differentiate chronic inflammatory demyelinating polyradiculoneuropathy from other chronic demyelinating polyneuropathies, are discussed. ESSENTIAL POINTS Chronic demyelinating neuropathies can present with overlapping clinical characteristics with seemingly subtle variations. It is clinically important to differentiate these types of neuropathies because the treatment and management can vary and affect prognosis.
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25
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Jagannath S, Anderson MA, Yee AJ, Hasserjian RP. Case 29-2023: A 34-Year-Old Woman with Abdominal Distention and Acute Kidney Injury. N Engl J Med 2023; 389:1133-1143. [PMID: 37733312 DOI: 10.1056/nejmcpc2027091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Affiliation(s)
- Sundar Jagannath
- From the Department of Hematology-Oncology, Mount Sinai Hospital, and the Department of Hematology-Oncology, Icahn School of Medicine at Mount Sinai - both in New York (S.J.); and the Departments of Radiology (M.A.A.), Medicine (A.J.Y.), and Pathology (R.P.H.), Massachusetts General Hospital, and the Departments of Radiology (M.A.A.), Medicine (A.J.Y.), and Pathology (R.P.H.), Harvard Medical School - both in Boston
| | - Mark A Anderson
- From the Department of Hematology-Oncology, Mount Sinai Hospital, and the Department of Hematology-Oncology, Icahn School of Medicine at Mount Sinai - both in New York (S.J.); and the Departments of Radiology (M.A.A.), Medicine (A.J.Y.), and Pathology (R.P.H.), Massachusetts General Hospital, and the Departments of Radiology (M.A.A.), Medicine (A.J.Y.), and Pathology (R.P.H.), Harvard Medical School - both in Boston
| | - Andrew J Yee
- From the Department of Hematology-Oncology, Mount Sinai Hospital, and the Department of Hematology-Oncology, Icahn School of Medicine at Mount Sinai - both in New York (S.J.); and the Departments of Radiology (M.A.A.), Medicine (A.J.Y.), and Pathology (R.P.H.), Massachusetts General Hospital, and the Departments of Radiology (M.A.A.), Medicine (A.J.Y.), and Pathology (R.P.H.), Harvard Medical School - both in Boston
| | - Robert P Hasserjian
- From the Department of Hematology-Oncology, Mount Sinai Hospital, and the Department of Hematology-Oncology, Icahn School of Medicine at Mount Sinai - both in New York (S.J.); and the Departments of Radiology (M.A.A.), Medicine (A.J.Y.), and Pathology (R.P.H.), Massachusetts General Hospital, and the Departments of Radiology (M.A.A.), Medicine (A.J.Y.), and Pathology (R.P.H.), Harvard Medical School - both in Boston
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Malhotra B, Sood A, Malhotra P, Bhadada S. POEMS syndrome: an unusual cause of exuberant callus formation. BMJ Case Rep 2023; 16:e252891. [PMID: 37699737 PMCID: PMC10503389 DOI: 10.1136/bcr-2022-252891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Several growth factors are expressed in distinct temporal and spatial patterns during fracture repair. Together, they lead to angiogenesis-osteogenesis coupling and hence bone healing by callus formation. Of these growth factors, vascular endothelial growth factor is of particular interest because of its ability to induce neovascularisation (angiogenesis) and osteoclast invasion in soft callus. Hyperplastic callus can be seen in metabolic bone disease, endocrine disease and in patients with traumatic brain injury, but has not been described so far in polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes (POEMS) syndrome. This report is a case of POEMS syndrome with unusual presentation in the form of exuberant callus formation at fracture sites.
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Affiliation(s)
- Bhanu Malhotra
- Endocrinology, PGIMER, Chandigarh, Haryana and Punjab, India
| | - Ashwini Sood
- Nuclear medicine, PGIMER, Chandigarh, Haryana and Punjab, India
| | - Pankaj Malhotra
- Hematology, Internal Medicine, PGIMER, Chandigarh, Haryana and Punjab, India
| | - Sanjay Bhadada
- Endocrinology, PGIMER, Chandigarh, Haryana and Punjab, India
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Gangat N, Szuber N, Tefferi A. JAK2 unmutated erythrocytosis: 2023 Update on diagnosis and management. Am J Hematol 2023; 98:965-981. [PMID: 36966432 DOI: 10.1002/ajh.26920] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/18/2023] [Accepted: 03/22/2023] [Indexed: 03/27/2023]
Abstract
DISEASE OVERVIEW JAK2 unmutated or non-polycythemia vera (PV) erythrocytosis encompasses a heterogenous spectrum of hereditary and acquired entities. DIAGNOSIS Foremost in the evaluation of erythrocytosis is the exclusion of PV through JAK2 (inclusive of exons 12-15) mutation screening. Initial assessment should also include gathering of previous records on hematocrit (Hct) and hemoglobin (Hgb) levels, in order to streamline the diagnostic process by first distinguishing longstanding from acquired erythrocytosis; subsequent subcategorization is facilitated by serum erythropoietin (Epo) measurement, germline mutation screening, and review of historical data, including comorbid conditions and medication list. Hereditary erythrocytosis constitutes the main culprit in the context of longstanding erythrocytosis, especially when associated with a positive family history. In this regard, a subnormal serum Epo level suggests EPO receptor mutation. Otherwise, considerations include those associated with decreased (high oxygen affinity Hgb variants, 2,3-bisphosphoglycerate deficiency, PIEZO1 mutations, methemoglobinemia) or normal oxygen tension at 50% Hgb saturation (P50). The latter include germline oxygen sensing pathway (HIF2A-PHD2-VHL) and other rare mutations. Acquired erythrocytosis commonly results from central (e.g., cardiopulmonary disease, high-altitude habitat) or peripheral (e.g., renal artery stenosis) hypoxia. Other noteworthy conditions associated with acquired erythrocytosis include Epo-producing tumors (e.g., renal cell carcinoma, cerebral hemangioblastoma) and drugs (e.g., testosterone, erythropoiesis stimulating agents, sodium-glucose cotransporter-2 inhibitors). Idiopathic erythrocytosis is an ill-defined terminology that presumes the existence of an increased Hgb/Hct level without an identifiable etiology. Such classification often lacks accounting for normal outliers and is marred by truncated diagnostic evaluation. MANAGEMENT Current consensus treatment guidelines are not supported by hard evidence and their value is further undermined by limited phenotypic characterization and unfounded concerns for thrombosis. We are of the opinion that cytoreductive therapy and indiscriminate use of phlebotomy should be avoided in the treatment of non-clonal erythrocytosis. However, it is reasonable to consider therapeutic phlebotomy if one were to demonstrate value in symptom control, with frequency determined by symptoms rather than Hct level. In addition, cardiovascular risk optimization and low dose aspirin is often advised. FUTURE DIRECTIONS Advances in molecular hematology might result in better characterization of "idiopathic erythrocytosis" and expansion of the repertoire for germline mutations in hereditary erythrocytosis. Prospective controlled studies are needed to clarify potential pathology from JAK2 unmutated erythrocytosis, as well as to document the therapeutic value of phlebotomy.
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Affiliation(s)
- Naseema Gangat
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Natasha Szuber
- Department of Hematology, Université de Montréal, Montréal, Quebec, Canada
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Rare forms of idiopathic multicentric Castleman disease presenting with intrahepatic cholestatic jaundice successfully treated with the bortezomib-based regimen: two case reports. Ann Hematol 2023; 102:977-979. [PMID: 36749403 DOI: 10.1007/s00277-022-05066-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/01/2022] [Indexed: 02/08/2023]
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Oyama T, Taoka K, Chiba A, Masamoto Y, Ikemura M, Honda A, Maki H, Kurokawa M. Daratumumab plus lenalidomide and dexamethasone for relapsed POEMS syndrome with bone plasmacytoma harboring 17p deletion. Int J Hematol 2023; 117:463-467. [PMID: 36202948 DOI: 10.1007/s12185-022-03459-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 10/10/2022]
Abstract
The standard therapies for polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes (POEMS) syndrome are radiation therapy, high-dose chemotherapy followed by autologous stem cell transplantation, and lenalidomide combined with dexamethasone. Daratumumab was reported to be effective for treatment-naive and relapsed POEMS syndrome, but treatment options for relapsed POEMS syndrome with poor prognostic factors or cytogenetic abnormalities have not been established due to a lack of studies in these patients. Here, we describe a case of relapsed POEMS syndrome with bone plasmacytoma harboring a newly detected 17p deletion after high-dose chemotherapy followed by autologous stem cell transplantation and radiation therapy in a male patient. He was successfully treated with daratumumab plus lenalidomide and dexamethasone (Dara-Rd). Dara-Rd could be effective in relapsed POEMS syndrome with 17p deletion, which is known as a poor cytogenetic abnormality in multiple myeloma. This report may broaden the application of Dara-Rd for POEMS syndrome.
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Affiliation(s)
- Takashi Oyama
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Kazuki Taoka
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Akira Chiba
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Yosuke Masamoto
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Masako Ikemura
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Akira Honda
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Hiroaki Maki
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Mineo Kurokawa
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan. .,Department of Cell Therapy and Transplantation Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan.
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30
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Magy L, Duchesne M, Frachet S, Vallat JM. Neuropatie periferiche. Neurologia 2023. [DOI: 10.1016/s1634-7072(22)47358-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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Hatano K, Orimo K, Ogura M, Okabe S, Ishida T, Kubota A, Shimizu J, Hashida H. Development of Polyneuropathy, Organomegaly, Endocrinopathy, M Protein, and Skin Changes Syndrome after Conversion from Plasmacytoma of Bone to Multiple Myeloma. Intern Med 2023; 62:475-479. [PMID: 35831107 PMCID: PMC9970814 DOI: 10.2169/internalmedicine.9101-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
A 36-year-old man developed polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes (POEMS) syndrome after conversion from solitary plasmacytoma of bone to multiple myeloma. Twenty-four days following the neurological onset, he lost his independent walking ability. The level of serum vascular endothelial growth factor (VEGF) at diagnosis was 5,250 pg/mL. Three months after initiating treatment, he regained his independent walking ability in line with a reduction in the elevated serum VEGF level. Due to their genomic instability gained during conversion, myeloma cells may overproduce humoral factors and cytokines, possibly contributing to the development of neuropathy as well as the production of VEGF.
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Affiliation(s)
- Keiko Hatano
- Department of Neurology, Japanese Red Cross Medical Center, Japan
| | - Kenta Orimo
- Department of Neurology, Japanese Red Cross Medical Center, Japan
| | - Mizuki Ogura
- Department of Hematology, Japanese Red Cross Medical Center, Japan
| | - Shingo Okabe
- Department of Neurology, Japanese Red Cross Medical Center, Japan
| | - Tadao Ishida
- Department of Hematology, Japanese Red Cross Medical Center, Japan
| | | | - Jun Shimizu
- Department of Neurology, The University of Tokyo, Japan
- Department of Physical Therapy, Faculty of Medical Health, Tokyo University of Technology, Japan
| | - Hideji Hashida
- Department of Neurology, Japanese Red Cross Medical Center, Japan
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Zhou XL, Chang YH, Li L, Ren J, Wu XL, Zhang X, Wu P, Tang SH. Polyneuropathy organomegaly endocrinopathy M-protein and skin changes syndrome with ascites as an early-stage manifestation: A case report. World J Clin Cases 2023; 11:135-142. [PMID: 36687199 PMCID: PMC9846972 DOI: 10.12998/wjcc.v11.i1.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/04/2022] [Accepted: 12/09/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Polyneuropathy organomegaly endocrinopathy M-protein and skin changes (POEMS) syndrome is a rare paraneoplastic syndrome caused by a potential plasma cell tumor. The clinical manifestations of POEMS syndrome are diverse. Due to the insidious onset and lack of specific early-stage manifestations, POEMS syndrome is easily misdiagnosed or never diagnosed, leading to delayed treatment. Neurological symptoms are usually the first clinical manifestation, while ascites is a rare symptom in patients with POEMS syndrome.
CASE SUMMARY A female patient presented with unexplained ascites as an initial symptom, which is a rare early-stage manifestation of the condition. After 1 year, the patient gradually developed progressive renal impairment, anemia, polyserosal effusion, edema, swollen lymph nodes on the neck, armpits, and groin, and decreased muscle strength of the lower extremities. The patient was eventually diagnosed with POEMS syndrome after multidisciplinary team discussion. Treatment comprised bortezomib + dexamethasone, continuous renal replacement therapy, chest and abdominal closed drainage, transfusions of erythrocytes and platelets, and other symptomatic and supportive treatments. The patient’s condition initially improved after treatment. However, then her symptoms worsened, and she succumbed to the illness and died.
CONCLUSION Ascites is a potential early manifestation of POEMS syndrome, and this diagnosis should be considered for patients with unexplained ascites. Furthermore, multidisciplinary team discussion is helpful in diagnosing POEMS syndrome.
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Affiliation(s)
- Xiao-Lei Zhou
- Graduate School, Southwest Medical University, Luzhou 646099, Sichuan Province, China
- Department of Gastroenterology, General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Ying-Hao Chang
- Department of Infectious Diseases, General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Lan Li
- Department of Gastroenterology, General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Juan Ren
- Department of Gastroenterology, General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Xiao-Ling Wu
- Department of Gastroenterology, General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Xue Zhang
- Department of Gastroenterology, General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Peng Wu
- Department of Gastroenterology, General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
| | - Shan-Hong Tang
- Graduate School, Southwest Medical University, Luzhou 646099, Sichuan Province, China
- Department of Gastroenterology, General Hospital of Western Theater Command, Chengdu 610083, Sichuan Province, China
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33
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Angeloudi E, Pappi E, Liakos A, Mainou M, Vlachaki E, Bekiari E. A rare case of POEMS syndrome presenting as essential thrombocythemia. Oxf Med Case Reports 2022; 2022:omac129. [PMID: 36540841 PMCID: PMC9759948 DOI: 10.1093/omcr/omac129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 08/21/2022] [Accepted: 09/26/2022] [Indexed: 12/23/2022] Open
Abstract
Polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes (POEMS) is a rare paraneoplastic syndrome, and its diagnosis is based on a series of clinical and laboratory findings. We present the case of a 46-year-old woman who was previously diagnosed with essential thrombocythemia. The patient complained about dyspnea on exertion, nausea, burning of the lower limbs, weight loss, recurrent episodes of lower back pain and polymenorrhea. Physical examination revealed hyperpigmentation, livedo reticularis of the lower limbs, sclerodermoid changes and plectrodactyly. A computed tomography-guided bone biopsy revealed the presence of plasmacytoma, and based on a combination of clinical features such as polyneuropathy, a diagnosis of POEMS syndrome has been established. The diagnosis of POEMS syndrome demands a high index of suspicion, especially in cases of peripheral neuropathy, peripheral edema or organomegaly of unknown origin. Since the syndrome can be fatal, early diagnosis is pivotal for patients' survival and quality of life.
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Affiliation(s)
- Elena Angeloudi
- Correspondence address. Second Department of Internal Medicine, Hippokration Hospital, Aristotle Univeristy of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece. Tel: +30-2310-892246; Fax: +30-2310-892246; E-mail:
| | - Eleni Pappi
- Second Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aris Liakos
- Second Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Mainou
- Second Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efthymia Vlachaki
- Second Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Bekiari
- Second Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Rekhtina I, Stolyarevich E, Zakharova E, Khyshova V, Mendeleeva L. A case of POEMS syndrome with severe kidney damage: lessons for the clinical nephrologist. J Nephrol 2022; 35:2135-2138. [PMID: 35737289 DOI: 10.1007/s40620-022-01379-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 06/07/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Irina Rekhtina
- Department of Chemotherapy of Plasma Cell Dyscrasias, National Medical Research Centre of Hematology, Moscow, Russian Federation
| | | | - Elena Zakharova
- Department of Nephrology, Botkin Hospital, 2-nd Borkinsky proezd 5, Building 11, 125284, Moscow, Russian Federation.
| | - Victoria Khyshova
- Department of Chemotherapy of Plasma Cell Dyscrasias, National Medical Research Centre of Hematology, Moscow, Russian Federation
| | - Larisa Mendeleeva
- Department of Chemotherapy of Paraproteinemic Blood Malignancies, National Medical Research Centre of Hematology, Moscow, Russian Federation
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Ma J, Chen Y, Qin X, Liu X, Li E, Fan H, Xie Y, Wang X. POEMS
syndrome: A rare cause of ascites and pelvic effusion. Clin Case Rep 2022; 10:e6603. [DOI: 10.1002/ccr3.6603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 10/16/2022] [Accepted: 10/31/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jing Ma
- Department of Gastroenterology, Tangdu Hospital The Air Force Military Medical University Xi'an China
| | - Yi Chen
- Department of Hematology, Tangdu Hospital The Air Force Military Medical University Xi'an China
| | - Xiaojin Qin
- Department of Gastroenterology, Tangdu Hospital The Air Force Military Medical University Xi'an China
| | - Xiaogang Liu
- Department of Gastroenterology, Tangdu Hospital The Air Force Military Medical University Xi'an China
| | - Ercui Li
- Department of Gastroenterology, Tangdu Hospital The Air Force Military Medical University Xi'an China
| | - Huijuan Fan
- Department of Gastroenterology, Tangdu Hospital The Air Force Military Medical University Xi'an China
| | - Yandong Xie
- Department of Gastroenterology, Tangdu Hospital The Air Force Military Medical University Xi'an China
| | - Xin Wang
- Department of Gastroenterology, Tangdu Hospital The Air Force Military Medical University Xi'an China
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Monoclonal Gammopathies of Clinical Significance: A Critical Appraisal. Cancers (Basel) 2022; 14:cancers14215247. [PMID: 36358666 PMCID: PMC9659226 DOI: 10.3390/cancers14215247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/15/2022] [Accepted: 10/24/2022] [Indexed: 11/26/2022] Open
Abstract
Simple Summary Monoclonal gammopathy of clinical significance (MGCS) refers to a recently coined term describing a complex and heterogeneous group of nonmalignant monoclonal gammopathies. These patients are characterized by the presence of a commonly small clone and the occurrence of symptoms that may be associated with the clone or with the monoclonal protein through diverse mechanisms. This is an evolving, challenging, and rapidly changing field. Patients are classified according to the key organ or system involved, with kidneys, skin, nerves, and eyes being the most frequently affected. However, multiorgan involvement may be the most relevant clinical feature at the presentation or during the course. This review delves into the definition, history, differential diagnosis, classification, prognosis, and treatment of this group of entities by analyzing the evidence accumulated to date from a critical perspective. Abstract Monoclonal gammopathies of clinical significance (MGCSs) represent a group of diseases featuring the association of a nonmalignant B cells or plasma cells clone, the production of an M-protein, and singularly, the existence of organ damage. They present a current framework that is difficult to approach from a practical clinical perspective. Several points should be addressed in order to move further toward a better understanding. Overall, these entities are only partially included in the international classifications of diseases. Its definition and classification remain ambiguous. Remarkably, its real incidence is unknown, provided that a diagnostic biopsy is mandatory in most cases. In fact, amyloidosis AL is the final diagnosis in a large percentage of patients with renal significance. On the other hand, many of these young entities are syndromes that are based on a dynamic set of diagnostic criteria, challenging a timely diagnosis. Moreover, a specific risk score for progression is lacking. Despite the key role of the clinical laboratory in the diagnosis and prognosis of these patients, information about laboratory biomarkers is limited. Besides, the evidence accumulated for many of these entities is scarce. Hence, national and international registries are stimulated. In particular, IgM MGCS deserves special attention. Until now, therapy is far from being standardized, and it should be planned on a risk and patient-adapted basis. Finally, a comprehensive and coordinated multidisciplinary approach is needed, and specific clinical trials are encouraged.
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Cell-Free and Concentrated Ascites Reinfusion Therapy during Hemodialysis for Intradialytic Hypotension and Intractable Ascites. Case Rep Nephrol 2022; 2022:7099227. [PMID: 36284565 PMCID: PMC9588379 DOI: 10.1155/2022/7099227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 09/11/2022] [Accepted: 10/06/2022] [Indexed: 11/07/2022] Open
Abstract
A 60-year-old woman with POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes) syndrome and intractable ascites presented with acute renal failure and received hemodialysis (HD) therapy. Due to frequent intradialytic hypotension, ultrafiltration with cell-free and concentrated ascites reinfusion therapy (CART) was performed to adequately manage the body fluid status and massive ascites. During HD with CART, her blood pressure was maintained compared with that during HD without CART, and an ultrafiltration volume of 3.7 L was achieved after HD with CART. In HD patients with intradialytic hypotension and massive ascites, the combination of CART and ultrafiltration during HD may be an effective therapeutic option for body-fluid management.
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Idiopathic Multicentric Castleman Disease with Cutaneous Manifestation: Case Report. Medicina (B Aires) 2022; 58:medicina58091222. [PMID: 36143899 PMCID: PMC9505402 DOI: 10.3390/medicina58091222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/28/2022] [Accepted: 09/02/2022] [Indexed: 11/17/2022] Open
Abstract
Castleman disease constitutes a rare class of lymphoproliferative disorders, with an estimated incidence of 21 to 25 per million patient years. The idiopathic subtype exhibits a significantly diverse clinical presentation, which can imitate many autoimmune, malignant, and infectious diseases. Cutaneous manifestations are uncommon and require in-depth investigation, especially when concurrent lymphadenopathy is present. A 79-year-old female, with a chronic, complicated erysipelas-like lesion, presented with bilaterally enlarged inguinal lymph nodes; after surgical excision, their histopathological examination revealed Castleman disease. Even though it is a benign condition, patients are often predisposed to developing certain types of malignancies, which can deteriorate their prognosis. An accurate and early diagnosis, along with effective treatment and prevention of recurrence, is of utmost importance in order to increase the patients’ overall survival and quality of life.
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Taenaka R, Shimokawa S, Katayama A, Nagao T, Obara T, Nishimura N, Tsujimoto A, Kohno K, Aoki K, Ogawa R. Successful treatment with daratumumab, lenalidomide, and dexamethasone therapy followed by autologous stem cell transplantation for newly diagnosed polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes syndrome: a case report. J Med Case Rep 2022; 16:311. [PMID: 35978379 PMCID: PMC9387014 DOI: 10.1186/s13256-022-03552-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/29/2022] [Indexed: 11/19/2022] Open
Abstract
Background Transplant-eligible patients with polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes syndrome are treated with induction therapy and autologous stem cell transplantation. Conventional induction therapies may exacerbate neuropathy and a high rate of disease progression within 5 years. Furthermore, only 50% of patients are able to walk independently after the therapies. Daratumumab, lenalidomide, and dexamethasone therapy has been reported as a less neurotoxic, highly effective therapy for patients with polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes syndrome who are ineligible for transplant or whose syndrome is relapsed/refractory, but no reports have provided data from untreated transplant-eligible patients. Case presentation A 34-year-old Japanese woman displayed weakness, pain and edema in the lower limbs, decreased grip strength, amenorrhea, and abdominal distention. She was unable to walk independently. The patient was diagnosed with polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes syndrome and performed four courses of daratumumab, lenalidomide, and dexamethasone therapy, which enabled her to walk independently and did not exacerbate the neuropathy. Hematopoietic stem cells were collected using plerixafor and filgrastim in combination. Autologous stem cell transplantation was performed with high-dose melphalan. At 3-month post-transplantation follow-up, most of her clinical symptoms had disappeared. Conclusions Daratumumab, lenalidomide, and dexamethasone therapy followed by autologous stem cell transplantation may be more effective than conventional therapy for newly diagnosed polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes syndrome. Although there was concerns that daratumumab, lenalidomide, and dexamethasone therapy might lead to poor mobilization of hematopoietic stem cells, this was overcome with the combination of plerixafor and filgrastim. The benefit of daratumumab, lenalidomide, and dexamethasone as induction therapy prior to autologous stem cell transplantation should be confirmed in future clinical trials.
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Affiliation(s)
- Ryutaro Taenaka
- Department of Hematology and Oncology, JCHO Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka, Japan. .,Department of Medicine and Biosystemic Sciences, Kyushu University Graduate School of Medicine, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, Fukuoka, Japan.
| | - Sakurako Shimokawa
- Department of Ophthalmology, JCHO Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka, Japan
| | - Ayako Katayama
- Department of Dermatology, JCHO Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka, Japan
| | - Toshihiko Nagao
- Department of Endocrinology and Metabolism, JCHO Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka, Japan
| | - Teppei Obara
- Department of Hematology and Oncology, JCHO Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka, Japan
| | - Naoaki Nishimura
- Department of Pharmacy, JCHO Kyushu Hospital, 1-8-1, Kishinoura, Yahatanisi-ku, Kitakyushu, Fukuoka, Japan
| | - Atsushi Tsujimoto
- Department of Neurology, JCHO Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka, Japan
| | - Kentaro Kohno
- Department of Hematology and Oncology, JCHO Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka, Japan
| | - Kenichi Aoki
- Department of Hematology and Oncology, JCHO Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka, Japan
| | - Ryosuke Ogawa
- Department of Hematology and Oncology, JCHO Kyushu Hospital, 1-8-1 Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka, Japan
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Hidekawa C, Yoshimi R, Kishimoto D, Kato H, Mitsuhashi M, Sakurai N, Sato Y, Uehara T, Iizuka Y, Komiya T, Hamada N, Nagai H, Soejima Y, Kamiyama R, Takase-Minegishi K, Kirino Y, Sakagami T, Nakajima H. Anti-interferon-γ Antibody-seropositive Disseminated Nontuberculous Mycobacterial Infection Mimicking POEMS and TAFRO Syndromes. Intern Med 2022; 61:2377-2385. [PMID: 35022342 PMCID: PMC9424072 DOI: 10.2169/internalmedicine.8366-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Disseminated nontuberculous mycobacterial infection (DNTM) is typically observed in immunocompromised hosts. Recently, it has been reported that healthy individuals with serum neutralizing autoantibodies for interferon (IFN)-γ can also develop DNTM. We herein report a case of anti-IFN-γ antibody-seropositive DNTM caused by Mycobacterium kansasii with symptoms mimicking TAFRO or POEMS syndrome, including anasarca, organomegaly, skin pigmentation, polyneuropathy, osteosclerotic change, thrombocytopenia, serum M protein, high C-reactive protein level, and reticulin fibrosis. The combination of antimicrobial chemotherapy with glucocorticoid and intravenous immunoglobulin improved his symptoms. Glucocorticoids may be an effective method of suppressing the production of anti-IFN-γ antibodies in DNTM.
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Affiliation(s)
- Chiharu Hidekawa
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Japan
| | - Ryusuke Yoshimi
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Japan
| | - Daiga Kishimoto
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Japan
| | - Hideaki Kato
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Japan
- Infection Prevention and Control Department, Yokohama City University Hospital, Japan
| | - Masaki Mitsuhashi
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Japan
| | - Natsuki Sakurai
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Japan
| | - Yuichiro Sato
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Japan
| | - Takeaki Uehara
- Department of Rheumatology, Chigasaki City Hospital, Japan
| | - Yuki Iizuka
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Japan
| | - Takaaki Komiya
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Japan
| | - Naoki Hamada
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Japan
| | - Hideto Nagai
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Japan
| | - Yutaro Soejima
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Japan
| | - Reikou Kamiyama
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Japan
| | - Kaoru Takase-Minegishi
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Japan
| | - Yohei Kirino
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Japan
| | - Takuro Sakagami
- Department of Respiratory Medicine, Faculty of Life Sciences, Kumamoto University, Japan
| | - Hideaki Nakajima
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Japan
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Kanuganti D, Nagarjunakonda VS, Bandarupalli P, Gorijala VK, Konagalla VLSR, Kowtha P. POEMS Syndrome: A Case Report and Review of the Literature. Cureus 2022; 14:e27001. [PMID: 35989837 PMCID: PMC9386312 DOI: 10.7759/cureus.27001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2022] [Indexed: 11/21/2022] Open
Abstract
Polyneuropathy, organomegaly, endocrinopathy, monoclonal protein elevation, and skin changes (POEMS) syndrome is a rare multisystem disorder that occurs due to an underlying plasma cell dyscrasia. A diagnosis is made with the presence of two mandatory criteria and at least one major and one minor criterion. We present a case of a 28-year-old patient who presented with weakness of bilateral arms and legs, thinning of hands, and swelling of bilateral lower limbs and abdomen. The patient also reported weight loss and loss of appetite. Examination revealed areflexic quadriparesis with sensory loss, diffuse lymphadenopathy, pleural effusion, ascites, and pulmonary hypertension. Investigations showed elevated erythrocyte sedimentation rate (ESR). Nerve conduction studies revealed severe axonal polyneuropathy of all nerves. Lymph node biopsy showed Castleman disease. A diagnosis of POEMS syndrome was made and he was sent for a stem cell transplant, which is the definitive treatment in patients eligible for stem cell transplant.
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Inoue K, Nagai K, Tsukada T, Iwase M, Sakata A, Ueda A, Yamagata K. POEMS Syndrome with Biclonal Gammopathy and Renal Involvement. Intern Med 2022; 61:2191-2196. [PMID: 35283379 PMCID: PMC9381336 DOI: 10.2169/internalmedicine.8714-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Polyneuropathy, Organomegaly, Endocrinopathy, M-protein and Skin changes (POEMS) syndrome manifests as elevated levels of vascular endothelial growth factor (VEGF) and monoclonal gammopathy. We treated a case of POEMS syndrome showing monoclonality in both IgA-λ and IgG-κ. Serial renal biopsies before treatment and after normalization of the VEGF levels suggested that glomerular microangiopathy had developed due to VEGF, while biclonal gammopathy was not eliminated. The renal pathology, proteinuria, and renal function all clearly improved. Although severe polyneuropathy limited activities of daily living and enforced a bedridden state, the patient dramatically regained his motor function, achieving crutch walking after induction of remission. This case is highly notable due to the presence of biclonality and repeated biopsies.
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Affiliation(s)
- Kohei Inoue
- Department of Nephrology, Hitachi General Hospital, Japan
| | - Kei Nagai
- Department of Nephrology, Hitachi General Hospital, Japan
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Japan
| | | | - Mamiko Iwase
- Department of Nephrology, Hitachi General Hospital, Japan
| | - Akiko Sakata
- Department of Pathology, Hitachi General Hospital, Japan
| | - Atsushi Ueda
- Department of Nephrology, Hitachi General Hospital, Japan
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Japan
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43
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Girard LP, Soekojo CY, Ooi M, Chng WJ, de Mel S. Immunoglobulin M Monoclonal Gammopathies of Clinical Significance. Front Oncol 2022; 12:905484. [PMID: 35756635 PMCID: PMC9219578 DOI: 10.3389/fonc.2022.905484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 05/05/2022] [Indexed: 01/07/2023] Open
Abstract
Immunoglobulin M monoclonal gammopathy of undetermined significance (MGUS) comprises 15-20% of all cases of MGUS. IgM MGUS is distinct from other forms of MGUS in that the typical primary progression events include Waldenstrom macroglobulinaemia and light chain amyloidosis. Owing to its large pentameric structure, IgM molecules have high intrinsic viscosity and precipitate more readily than other immunoglobulin subtypes. They are also more commonly associated with autoimmune phenomena, resulting in unique clinical manifestations. Organ damage attributable to the paraprotein, not fulfilling criteria for a lymphoid or plasma cell malignancy has recently been termed monoclonal gammopathy of clinical significance (MGCS) and encompasses an important family of disorders for which diagnostic and treatment algorithms are evolving. IgM related MGCS include unique entities such as cold haemagglutinin disease, IgM related neuropathies, renal manifestations and Schnitzler's syndrome. The diagnostic approach to, and management of these disorders differs significantly from other categories of MGCS. We describe a practical approach to the evaluation of these patients and our approach to their treatment. We will also elaborate on the key unmet needs in IgM MGCS and highlight potential areas for future research.
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Affiliation(s)
- Louis-Pierre Girard
- Aberdeen Royal Infirmary, National Health Service Grampian, Scotland, United Kingdom
| | - Cinnie Yentia Soekojo
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
| | - Melissa Ooi
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
| | - Wee Joo Chng
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sanjay de Mel
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
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Qian S, Ding M, Hou H, Wang Z, Zhang J, Zhang Y, Dong M, Zhu L, Wang G, Li W, Zhang X. Clinical and Molecular Characteristics of 60 Patients With Human Immunodeficiency Virus-Negative Castleman Disease. Front Immunol 2022; 13:899073. [PMID: 35655778 PMCID: PMC9152317 DOI: 10.3389/fimmu.2022.899073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/19/2022] [Indexed: 11/29/2022] Open
Abstract
Castleman disease (CD) is a rare lymphoproliferative disorder. The mechanistic target of rapamycin (mTOR) pathway is a key regulator of various cellular functions, which may be related with the potential mechanisms of CD occurrence. We retrospectively collected the clinical information of 60 CD patients diagnosed in the First Affiliated Hospital of Zhengzhou University. And FFPE biopsy specimens were collected from 31 patients (12 unicentric CD patients and 19 multicentric CD patients) to detect the mTOR pathway protein expression. We are the first to demonstrate that thrombocytopenia and hypoalbuminemia are independent poor prognostic factors for CD. Moreover, mTOR activation was higher in CD compared to reactive lymphoid hyperplasia (used as a control group). This study offers some elucidation for the management and treatment of CD patients.
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Affiliation(s)
- Siyu Qian
- Department of Oncology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Mengjie Ding
- Department of Oncology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Huting Hou
- Department of Oncology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Zeyuan Wang
- Department of Oncology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Jieming Zhang
- Department of Oncology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Yue Zhang
- Department of Oncology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Meng Dong
- Department of Oncology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Linan Zhu
- Department of Oncology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Guannan Wang
- Department of Pathology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wencai Li
- Department of Pathology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xudong Zhang
- Department of Oncology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
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Du K, Chu X, Tang Y, Zhao X, Yu M, Zheng Y, Deng J, Lv H, Zhang W, Wang Z, Yuan Y, Meng L. Patterns of myelinated nerve fibers loss in transthyretin amyloid polyneuropathy and mimics. Ann Clin Transl Neurol 2022; 9:1059-1068. [PMID: 35665499 PMCID: PMC9268867 DOI: 10.1002/acn3.51599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/02/2022] [Accepted: 05/12/2022] [Indexed: 11/10/2022] Open
Abstract
Objective The present study was intended to analyze the characteristics of myelinated nerve fibers density (MFD) of transthyretin amyloid polyneuropathy (ATTR‐PN) and other similar neuropathies. Methods A total of 41 patients with ATTR‐PN, 58 patients of other common peripheral neuropathies, and 17 age‐and gender‐matched controls who visited the First Hospital of Peking University and performed sural nerve biopsy between June 2007 and August 2021 were included for analysis of MFD. Results Except the vasculitic neuropathy group, the total and small MFD of patients in the ATTR‐PN group were significantly lower than those of other disease groups. There was an obvious negative correlation between the total MFD and the disease course in the ATTR‐PN group. The disease course of early‐onset and late‐onset symptoms was similar, but the loss of large myelinated nerve fibers (MF) was more severe for the latter. In addition, all late‐onset and most early‐onset patients had severely reduced MFD after a 2 years' disease course. The MFD in ATTR‐PN patients was negatively correlated with Neuropathy Impairment Score (NIS) and Norfolk Quality of life‐diabetic neuropathy (Norfolk QOL‐DN) score. Conclusion MF is lost differently in ATTR‐PN and in other common peripheral neuropathies. The late‐onset and early‐onset ATTR‐PN patients have different patterns of loss of large and small MF.
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Affiliation(s)
- Kang Du
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Xujun Chu
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Yuwei Tang
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Xutong Zhao
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Meng Yu
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Yiming Zheng
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Jianwen Deng
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - He Lv
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Wei Zhang
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Zhaoxia Wang
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Yun Yuan
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
- Beijing Key Laboratory of Neurovascular Disease Discovery Beijing 100034 China
| | - Lingchao Meng
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
- Beijing Key Laboratory of Neurovascular Disease Discovery Beijing 100034 China
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Ainai S, Komaki R, Muramae N, Uno R, Mori K, Otsui K, Yakushijin K, Sakaguchi K. Biclonal Gammopathy as a Misleading Indicator to Diagnose POEMS Syndrome: An Autopsy Case Report and a Review of the Literature. Cureus 2022; 14:e25153. [PMID: 35747029 PMCID: PMC9206714 DOI: 10.7759/cureus.25153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 12/03/2022] Open
Abstract
A 76-year-old man presented with a four-month history of progressive bilateral lower limb muscle weakness and dysesthesia. The patient had extravascular volume overload, and laboratory findings confirmed hypothyroidism, renal dysfunction, and chronic inflammation. Serum protein and immunofixation electrophoresis revealed biclonality of immunoglobulin A (IgA)-kappa and IgA-lambda, which was attributed to chronic inflammation. Subsequently, we detected the proliferation of monoclonal plasma cells in the bone marrow, which led to a diagnosis of POEMS syndrome. Despite the initiation of chemotherapy, the patient died of aspiration pneumonia. In this case, biclonal gammopathy in peripheral blood delayed a diagnosis of POEMS syndrome.
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Takahashi Y, Mochizuki Y, Nakamura K, Katoh N, Sekijima Y. Moyamoya Disease-like Cerebrovascular Stenotic Lesions Are an Important Phenotype of POEMS Syndrome-associated Vasculopathy. Intern Med 2022; 61:1603-1608. [PMID: 34744103 PMCID: PMC9177367 DOI: 10.2169/internalmedicine.7701-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 41-year-old woman was diagnosed with polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes (POEMS) syndrome based on polyneuropathy, hepatosplenomegaly, sclerotic bone lesions, IgA-λ M-protein, and an elevated level of serum vascular endothelial growth factor. One month after the initiation of lenalidomide-dexamethasone with prophylactic aspirin, she developed facial paralysis, dysarthria, and left hemiplegia. Multiple cerebral infarctions and internal carotid artery stenosis were detected. Five months after switching to pomalidomide-dexamethasone, she again developed cerebral infarction. Progressed stenotic lesions in the bilateral internal carotid artery terminal portions were detected, showing a moyamoya disease-like appearance. Quasi-moyamoya disease can be an important phenotype of systemic vasculopathies of POEMS syndrome.
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Affiliation(s)
- Yusuke Takahashi
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
| | - Yusuke Mochizuki
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
| | | | - Nagaaki Katoh
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
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48
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Belabbes F, Houda Y, Al Bouzidi A, Bennani Y, Ahnach M. Polyneuropathy, Organomegaly, Endocrinopathy, M-protein, and Skin Changes (POEMS) Syndrome and Idiopathic Portal Hypertension: A Rare Association. Cureus 2022; 14:e24923. [PMID: 35698702 PMCID: PMC9187135 DOI: 10.7759/cureus.24923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2022] [Indexed: 12/04/2022] Open
Abstract
Polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes (POEMS) syndrome is a paraneoplastic syndrome due to an underlying plasma cell neoplasm. The diagnosis of POEMS syndrome is made with three of the major criteria, two of which must include polyradiculoneuropathy and clonal plasma (PCD), and at least one of the minor criteria. The most frequent liver manifestation is hepatomegaly. Idiopathic portal hypertension (IPH) has been reported rarely in POEMS syndrome. The precise etiopathogenesis of IPH is not fully elucidated. We report a 46-year-old male patient presenting with POEMS syndrome. He presented postprandial vomiting and left tinnitus. Loss of appetite, leanness, and excessive sweat were concomitant symptoms. Abdominal examination revealed splenomegaly and an absence of hepatomegaly. Abdominal ultrasonography was therefore performed, revealing hepatosplenomegaly with dilatation of the splenic vein. An abdominal computed tomography confirmed the presence of an 18.5 cm splenomegaly with dilatation of the splenic and portal vein. Upper endoscopy with biopsy showed minimal, non-atrophic, mildly active chronic, follicular antrofundic gastritis without esophageal varices. Laboratory and radiological examinations could not confirm the etiology of portal hypertension. The liver biopsy suggested hepatoportal sclerosis, compatible with IPH. The patient initially received six courses of the CTD (cyclophosphamide, thalidomide, and dexamethasone) protocol. He subsequently proceeded to an autologous stem cell transplant (ASCT), and the patient achieved a considerable improvement. POEMS syndrome could be complicated with IPH. There are only a few cases of IPH associated with POEMS syndrome in the literature. This case highlights the manifestation of portal hypertension in POEMS syndrome.
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Horna P, King RL, Jevremovic D, Fajgenbaum DC, Dispenzieri A. The lymph node transcriptome of unicentric and idiopathic multicentric Castleman disease. Haematologica 2022; 108:207-218. [PMID: 35484648 PMCID: PMC9827154 DOI: 10.3324/haematol.2021.280370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Indexed: 02/05/2023] Open
Abstract
Castleman disease is a polyclonal lymphoproliferative disorder characterized by unicentric or multicentric lymphadenopathy with characteristic histomorphological features, in addition to variable inflammatory symptomatology. The molecular mechanisms and etiologies of unicentric Castleman disease (UCD) and idiopathic multicentric Castleman disease (iMCD) are poorly understood, and identification of targetable disease mediators remains an unmet clinical need. We performed whole exome sequencing on lymph node biopsies from patients with UCD and iMCD and compared the transcriptomic profiles to that of benign control lymph nodes. We identified significantly upregulated genes in UCD (n=443), iMCD (n=316) or both disease subtypes (n=51) and downregulated genes in UCD (n=321), iMCD (n=105) or both (n=10). The transcriptomes of UCD and iMCD showed enrichment and upregulation of elements of the complement cascade. By immunohistochemistry, C4d deposits indicative of complement activation were found to be present in UCD and iMCD, mostly within abnormally regressed germinal centers, but also in association with plasma cell clusters, endothelial cells and stroma cell proliferations. Other enriched gene sets included collagen organization, S1P3 pathway and VEGFR pathway in UCD; and humoral response, oxidative phosphorylation and proteosome in iMCD. Analysis of cytokine transcripts showed upregulation of CXCL13 but not IL6 in UCD and iMCD. Among angiogenic mediators, the VEGFR1 ligand placental growth factor (PGF) was upregulated in both disease subtypes. We hereby report for the first time the whole lymph node transcriptomes of UCD and iMCD, underscoring findings that could aid in the discovery of targetable disease mediators.
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Affiliation(s)
- Pedro Horna
- Division of Hematopathology, Mayo Clinic, Rochester, MN,P. Horna
| | | | | | - David C. Fajgenbaum
- Center for Cytokine Storm Treatment & Laboratory, University of Pennsylvania, Philadelphia, PA
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POEMS Syndrome: Presented as Idiopathic Multicentric Castleman Disease of Plasma Cell Variant for Eight Years and Dramatic Treatment with Siltuximab Followed by Autologous Peripheral Blood Stem Cell Transplantation. Diagnostics (Basel) 2022; 12:diagnostics12040998. [PMID: 35454046 PMCID: PMC9031929 DOI: 10.3390/diagnostics12040998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 02/01/2023] Open
Abstract
Background: POEMS syndrome (POEMS) is a rare plasma cell clonal paraneoplastic syndrome consisting of polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes presenting with idiopathic multicentric Castleman disease (iMCD) histology, the treatment of which has not yet been well established. iMCD is also a distinctive rare non-clonal lymphoproliferative disorder, of which dramatic response to Siltuximab, a monoclonal anti-IL-6 antibody, has been reported recently. Methods: the differential diagnosis between POEMS and iMCD can be very challenging because of the identical histology, overlapping similar symptoms such as polyneuropathy, and vital signs insidiously presented to diagnose POEMS. Results: here, we report the case of a 53-year-old man with iMCD treated for 8 years developing sequential polyneuropathy, monoclonal gammopathy, and bone lytic lesions, all of which were confirmed after his iMCD achieved complete remission resulting from siltuximab administration and finally confirmed as POEMS. Conclusions: we describe the clinical ambiguity of disease presenting that we can face in the real world between iMCD and POEMS and emphasise careful, enduring observation lasting several years.
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