Unusual manifestations of monoclonal gammopathies. Autoimmune and idiopathic syndromes

[Pseudo-Glanzmann thrombasthenia in the course of autoimmune thrombocytopenic purpura]

INTRODUCTION

Auto-immune thrombocytopenic purpura is associated with platelet anti-glycoprotein antibodies, particularly with anti-GPIIb/IIIa complex. Persistence of these antibodies sometimes leads to acquired auto-immune thrombopathy.

EXEGESIS

We report the case of a woman treated by splenectomy for auto-immune thrombocytopenic purpura, who developed 5 years later an ecchymotic syndrome despite normal platelet count. High bleeding time and platelet aggregation defect in vitro were evidenced. Following the initial thrombocytopenia, anti-glycoproteins GPIIb/IIIa with lupus anticoagulant and benign monoclonal gammapathy were noticed. Platelet controls showed that hypoaggregant activity was secondary to the persistence of anti-GPIIb/IIa antibodies.

CONCLUSION

This acquired auto-immune thrombopathy simulating Glanzmann's thrombasthenia was secondary to the persistence of platelet anti-glycoproteins GPIIb/IIIa.

Development of a "Myeloma Risk Score" using a population-based registry on paraproteinemia and myeloma

Diagnostic systems for monoclonal gammopathies use bone marrow and X-ray examinations to exclude multiple myeloma (MM). Data from a population-based registry of unselected patients with paraproteinemia indicate that these tests are often done only when MM is suspected. We used 441 randomly selected patients to develop a simple four point "Myeloma Risk Score" based on two readily available laboratory tests. One point was given for paraprotein concentration > or = 10 g/l, one point for IgG and IgA, and two points for IgD and light chains only. A score of 0 or 1 indicated a low risk for MM, with scores of 2 and 3 signifying high risks. Sensitivity, specificity, positive and negative predictive value (PV) for the Myeloma Risk Score in the training sample were 92%, 88%, 79%, and 96% respectively. Extrapolating these results to a larger cohort showed that 90% of patients with a monoclonal gammopathy could be classified correctly as having MM or a non-myeloma condition. The Myeloma Risk Score can identify patients with a paraproteinemia at risk for MM, and who are therefore candidates for bone marrow and X-ray examination.

Developing a population-based registry for patients with paraproteinemias or multiple myeloma

The development of a population-based registry on paraproteinemia and multiple myeloma is described. A unique feature of this registry is the multidisciplinary approach to obtain and collect new cases. Clinical chemists, internists, hematologists, and pathologists could all enter patients. All patients newly diagnosed in the mid-western part of The Netherlands (1.7 million inhabitants in 1992) with a paraproteinemia or multiple myeloma in 1991, 1992, and 1993 were included. The project was composed of a registry of clinical and laboratory data extracted from the patient's records, storage of 1 ml serum at diagnosis, and a yearly follow-up. A total of 1832 entries was received, of which 83% met the inclusion criteria. Comparison of this database with the Regional Cancer Registry showed that the paraprotein registry was successful as far as registration of myeloma patients was concerned. We conclude that the multidisciplinary approach used in this paraprotein registry is feasible and has resulted in a unique collection of patients for studying potential pre-malignant conditions such as paraproteinemia.

B cell superantigens: potential modifiers of the normal human B cell repertoire

Staphylococcal protein A (SPA), HIV gp120, and staphylococcal enterotoxins (SE) are B cell superantigens that induce VH specific B cell responses. In addition, the red blood cell antigens, i/I, have some features of a B cell superantigen. Binding of SPA, SE and HIV gp120 are VH family specific, whereas binding of i/I is VH gene specific. SPA and HIV gp120 function by stimulating VH3-expressing B cells, whereas SE appear to function by enhancing survival of the appropriate VH-expressing B cells. Moreover, HIV gp120 has been shown to delete VH3-expressing B cells. In this review, we describe evidence that shows how these superantigens may play a role in shaping the normal B cell repertoire.

Follicular spicules of the nose: a peculiar cutaneous manifestation of multiple myeloma with cryoglobulinemia

We describe a patient with multiple myeloma and cryoglobulinemia who had spicules with a horny appearance in the follicular openings of the face, particularly on the nose. Histopathologic study demonstrated that these spicules consisted of eosinophilic homogeneous deposits in the intercellular spaces between keratinocytes in the upper layers of the follicular infundibulum. Direct immunofluorescence, ultrastructural, and biochemical investigations revealed that these eosinophilic deposits were cryoprecipitates composed of IgG-kappa with electrophoretic characteristics identical to those of the paraprotein present in the serum of the patient. Hence we believe that these lesions are best referred to as pseudohyperkeratotic spicules of the nose, and that they are a characteristic cutaneous manifestation of patients with multiple myeloma and cryoglobulinemia.

Is the Durie and Salmon diagnostic classification system for plasma cell dyscrasias still the best choice? Application of three classification systems to a large population-based registry of paraproteinemia and multiple myeloma

There are a number of systems for diagnosing multiple myeloma, myeloma variants and monoclonal gammopathy of undetermined significance. We compared three systems, those according to Durie and Salmon, to Kyle and Greipp, and to the British Columbia Cancer Agency, using material from a population-based registry of 847 patients with a paraproteinemia or multiple myeloma. Of these, 157 underwent both bone marrow and X-ray examinations and were subsequently included in our analysis. The differences between the systems were small, even though in only 64% of the cases the diagnosis according to all three systems was identical. The system used by the British Columbia Cancer Agency turned out to be the shortest and easiest system reviewed here. We propose a more frequent application of this system instead of the more commonly used Durie and Salmon and Kyle and Greipp criteria.

Two-dimensional polyacrylamide gel electrophoresis analysis of cryoglobulins and identification of an IgM-associated peptide

The clonality of immunoglobulins (Igs) in cryoprecipitates (n = 41) was studied by two-dimensional polyacrylamide gel electrophoresis (2-D PAGE). Our series included 24 cryoglobulins characterized by immunofixation electrophoresis (IF), 12 'trace amount' cryoglobulins, defined by a protein content in the precipitate of less than 0.05 mg/ml of serum, and five cryoglobulins of undetermined protein composition by IF. 2-D PAGE analysis showed polyclonal IgG associated either with monoclonal Igs (type II cryoglobulins; n = 14) or with polyclonal IgM (type III cryoglobulins; n = 14). In ten cryoprecipitates (two 'trace amount' cryoglobulins as well as seven of 19 type II and as one of five type III cryoglobulins by IF) polyclonal IgG were associated with a mixture of polyclonal and monoclonal IgM. These cryoglobulins were tentatively named type II-III cryoglobulins. A monoclonal IgM was observed in one cryoprecipitate (type I cryoglobulins). Two cryoglobulins presented unexpected 2-D patterns, characterized by the presence of oligoclonal IgM, with trace amounts of Igs of different isotypes (tentatively named type II-III(variant) cryoglobulins). A peptide of 44 kDa with a pI of 5.45 was observed in all cryoglobulins containing IgM (n = 40). This peptide was also present in purified monoclonal or polyclonal IgM fractions. N-terminal microsequencing (12 amino acid residues) revealed that this IgM-associated peptide was an unknown protein. Our results highlight the role of 2-D PAGE as an aid in the analysis of cryoglobulins.

Pattern variations of polyclonal and monoclonal immunoglobulins of different isotypes analyzed by high-resolution two-dimensional electrophoresis

High-resolution two-dimensional polyacrylamide gel electrophoresis (2-D PAGE) was used to analyze serum samples and purified immunoglobulins (Ig) obtained from "normal" individuals and from patients diagnosed with monoclonal gammopathies (MG) (n = 47; 5 IgA, 15 IgM, 15 IgG, 4 biclonal IgG, 1 IgD, 7 Bence Jones proteins). Polyclonal and monoclonal heavy (H) chains were located at different restricted gel positions according to their isotype. Monoclonal H chains appeared as sets of spots characterized by charge (pI) and size (M(r)) microheterogeneity. Most of the monoclonal gamma chains were not seen on the gels (12/15). Supplementary polypeptides of 45-48 kDa were detected in serum samples containing monoclonal IgM, but were not seen in MG of other isotypes. However, these polypeptides were not specifically associated with monoclonal IgM because they were also found on protein maps of purified polyclonal IgM. Polyclonal light (L) chains appeared as cloudy bands containing several zones of higher density, whereas monoclonal L chains were usually resolved as single sharp spots. In 6 samples, monoclonal L chains were not seen, and in 9 samples, they appeared as two or more spots, characterized by different pI and/or M(r). In one sample obtained from a patient with a biclonal gammopathy, the L chains were resolved as 4 different spots. Our results confirm that 2-D PAGE is an excellent tool to study Ig. Analysis of the L chain region of the gels was particularly informative. Several monoclonal L chains exhibited heterogeneous two-dimensional spot patterns, suggesting that "subtile" clonal mutations of B-cell lineage and/or posttranslational modifications were involved in their production.

Clonality of cold agglutinins in patients with hemolytic anemia: an analysis by high-resolution two-dimensional gel electrophoresis

High-resolution two-dimensional gel electrophoresis (2-DGE) was used to analyse plasma samples and partially purified cold agglutinins (CA) obtained from two selected patients. Both presented an acute hemolytic anemia with CA of high thermal amplitude, normal immunoglobulin levels, no detectable paraproteinemia, and no clinical evidence of a malignant B-cell disorder. The electrophoretograms of their plasma showed evident alternations of the "normal" protein profile, which were directly related to hemolysis (absence of the spots of haptoglobin and in one case of those of hemopexin), but no monoclonal gammopathy. The electrophoretograms of their purified CA revealed two clearly different spot patterns respectively corresponding to a monoclonal IgM and to polyclonal IgM. These results show that the clonality of CA associated with hemolytic anemia can be easily determined by 2-DGE. This technique may be very useful to discriminate chronic cold agglutinin disease in the early phase from "parainfectious" CA.

Two IgM paraproteins bearing cryoglobulin and anti-smooth muscle activities in a patient with Waldenström's macroglobulinaemia

A 52-year-old white male subject with typical clinical and laboratory findings of Waldenström's macroglobulinaemia is described. Two paraprotein peaks of IgM lambda class, with different physical and chemical properties and different amino acid compositions, in both heavy and light chains, were found in the patient's serum. One of the IgM components (M1) was a cryoglobulin, and the other (M2) showed strong antismooth muscle activity. As far as we know, this is the first report of double paraproteins each of which has different properties.

Monoclonal gammopathies: new approaches to clinical problems in diagnosis and prognosis

When a patient presents with monoclonal gammopathy, a wide variety of clinical conditions must be considered. The importance of distinguishing accurately between patients with stable monoclonal gammopathies and those with overt multiple myeloma cannot be over-emphasised. The bone marrow examination with plasma cell labeling index, and newer techniques such as magnetic resonance imaging and computed tomography can improve diagnostic discrimination. In difficult cases, the detection of small numbers of circulating myeloma cells, the peripheral blood B-cell labeling index, and light chain isotype suppression may bring better diagnostic resolution. These tests may also be used to help assess disease activity. If the diagnosis is multiple myeloma, prediction of outcome assumes clinical importance. There are widely disparate survivals among patients with different clinical presentations. Standard clinical assays or a combination of these as in clinical staging do not provide sufficient prediction of outcome but are routinely available and therefore widely used. Independent predictive tests such as the plasma cell labeling index and beta 2-microglobulin improve prognostic accuracy. Ploidy analysis and immunophenotyping are additional variables that may assume more importance as the results of ongoing studies appear. Other promising approaches include detection of oncogene and multiple drug resistance gene expression. All such techniques will become more relevant as we apply more intensive treatment earlier in the disease course, particularly for the younger myeloma patients in whom the prognosis is poor.

[Two-dimensional electrophoretic study of monoclonal gammopathies and cold agglutinins associated with a chronic hemolytic anemia]

Two-dimensional gel electrophoresis (2-DGE) associated with a very sensitive silver staining is one of the most powerful technique available for protein analysis. Proteins are separated in the first dimension by isoelectric focusing in a pH gradient, and in the second dimension by polyacrylamide gel electrophoresis. Proteins are thus separated according to their charge and to their size. The high resolution of 2-DGE allows the analysis of complex mixture of proteins with a great reproducibility. More than hundred different proteins can be individualized after 2-DGE of plasma or serum samples. Using this technique, we analysed samples obtained from normal donors and from patients with different gammopathies. Our results confirm that the heavy chains of immunoglobulins are easily detected and that the alpha, gamma and mu chains are clearly differentiated from one another. The typical polyclonal heavy and light chains appear as indiscrete spots after staining of the gels. On the contrary, the monoclonal chains appear as discrete spots. Monoclonal heavy chains have a restricted charge heterogeneity. We also analysed cold agglutinins, partially purified from plasma of three patients showing evidence of chronic hemolysis, a positive direct antiglobulin test of the complement type and anti-I autoantibodies. The 2-DGE have clearly demonstrated that these cold agglutinins were monoclonal IgM, when these later were not detectable by immunofixation electrophoresis. We think that the 2-DGE is a very usefull specialized aid to the analysis of such particular immunohematological problems.

Refractory ascites due to POEMS syndrome

A 52-yr-old woman developed exudative ascites 2 yr after the onset of peripheral neuropathy. Extensive evaluation revealed that the patient had no underlying liver disease, malignancy, infection, or cardiac or renal disease. The ascites initially responded to high-dose corticosteroid therapy. The patient had many clinical features of the recently described POEMS syndrome, including a persistent IgA lambda-paraprotein. Initially, her ascites responded to treatment with steroids. This is characteristic of the syndrome and should be considered in patients with POEMS syndrome and refractory ascites.

Antibody specificity of the human monoclonal immunoglobulins: the elusive target antigen

Human monoclonal immunoglobulins (HMIGs) are encountered in different clinical conditions mainly including (auto)immune disorders, immunodeficiencies and B-cell malignancies. However, in some cases no associated-disease is evidenced and they are considered as "idiopathic". Their incidence increases with age. The factors involved in the emergence and regulation of the growth and differentiation of B-cell clones secreting HMIGs are unknown but might implicate T-cell dysfunction. One approach to elucidate the origin of such B-cell clones is to identify the putative target antigen. For this reason, we have reviewed the antibody (Ab) specificity of 8439 HMIGs described in the literature, the data coming from 24 systematic screenings. Very few HMIGs present anti-hapten activity (1%) or specificity for foreign antigens (0.3%). On the other hand, the data quoted strongly document an auto-Ab (Ab1 type) activity in a large percentage of the HMIGs, mainly of the IgM type (at least greater than 30%), with properties similar to those of naturally occurring auto-Abs. Furthermore, there is some evidence that HMIGs may express anti-idiotypic activity (Ab2) to human (auto)-Abs. Finally, many of the HMIGs which are devoid of detectable auto-Ab activity (i.e., mainly IgG, IgA) share cross-reactive idiotypes with natural auto-Abs. It may be speculated that some of these HMIGs actually represent either Ab of the Ab3 type i.e., anti-anti-idiotypic Ab to auto-Abs or Ab which have varied sufficiently to loose auto-or-foreign-antigen-binding activity but maintaining idiotype. As a whole, these data demonstrate that many HMIGs are the secretory products of the auto-reactive B-cell clones which produce natural auto-Abs (including anti-idiotypic and anti-anti-idiotypic Abs) and which are characterized by a very high degree of idiotypic connection. Since HMIGs arise from such clones, it may be postulated that the emergence of HMIGs might be due to a dysfunction of the system that normally regulates such an Ab production.