Cutaneous light chain amyloidosis with multiple myeloma: A concise review

Episodic Upper Eyelid Edema in an African American Patient

An African American patient in their 60s with a history of monoclonal gammopathy of unknown significance presents to the oculoplastic service for intermittent, bilateral upper eyelid swelling and pain for 2 years. Examination reveals hyperpigmented, spongy eyelid edema with redundant skin, and no lymphadenopathy is present. What would you do next?

An Overview of Clinical Manifestations of Dermatological Disorders in Intensive Care Units: What Should Intensivists Be Aware of?

Acute skin failure is rarely the primary diagnosis that necessitates admission to an intensive care unit. Dermatological manifestations in critically ill patients, on the other hand, are relatively common and can be used to make a key diagnosis of an adverse drug reaction or an underlying systemic illness, or they may be caused by factors related to a prolonged stay or invasive procedures. In intensive care units, their classification is based on the aetiopathogenesis of the cutaneous lesion and, in the meantime, distinguishes critical patients. When evaluating dermatological manifestations, several factors must be considered: onset, morphology, distribution, and associated symptoms and signs. This review depicts dermatological signs in critical patients in order to lay out better recognition.

Case report: Vesiculobullous eruption with an atypical IgA deposition pattern in a patient with multiple myeloma-A case report and literature review

Cutaneous vesiculobullous eruptions associated with multiple myeloma (MM) are rare. Although the development of blisters is mostly driven by amyloid deposits of paraproteins in the skin, autoimmunity may play a role. In this study, we report an unusual case of an MM patient with blisters who presented with both flaccid and tense vesicles and bullae. Direct immunofluorescence revealed IgA autoantibody deposits in the basement membrane zone (BMZ) and intercellular space of the epidermis, which displayed an atypical autoantibody deposition pattern. The patient showed rapid disease progression and died during follow-up. We performed a literature review of autoimmune bullous diseases (AIBDs) associated with MM or its precursors and found 17 previously reported cases. Together with the present case, cutaneous involvement of the skin folds was frequently reported, and mucous membranes were barely affected. IgA pemphigus, with consistent IgA monoclonality, was observed in half of the cases. Five patients displayed atypical autoantibody deposition patterns in the skin; the prognosis of these patients appeared to be poorer than that of other patients. We aim to increase our understanding of AIBDs associated with MM or its precursors.

Amyloidoma and Plasmacytoma Presented as a Solitary Lung Nodule in a Patient of Multiple Myeloma With AL-Amyloidosis: A Case Report and Review of Literature

Nodular amyloidoma in the lungs is a rare entity, also the occurrence of extramedullary plasmacytoma (EMP) in the lungs is rare. To have concomitant EMP and amyloidoma presented as a single lung mass is even rarer. There was only one similar case reported in the abstract form previously. Our case did not respond to many novel chemotherapy agents, suggesting that this combination of amyloidoma and plasmacytoma belonged to a poor prognosis entity, requiring different treatment modalities, such as early bone marrow transplantation or CART (chimeric antigen receptors T) therapy.

Identification and mechanistic basis of non-ACE2 blocking neutralizing antibodies from COVID-19 patients with deep RNA sequencing and molecular dynamics simulations

Variants of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) continue to cause disease and impair the effectiveness of treatments. The therapeutic potential of convergent neutralizing antibodies (NAbs) from fully recovered patients has been explored in several early stages of novel drugs. Here, we identified initially elicited NAbs (Ig Heavy, Ig lambda, Ig kappa) in response to COVID-19 infection in patients admitted to the intensive care unit at a single center with deep RNA sequencing (>100 million reads) of peripheral blood as a diagnostic tool for predicting the severity of the disease and as a means to pinpoint specific compensatory NAb treatments. Clinical data were prospectively collected at multiple time points during ICU admission, and amino acid sequences for the NAb CDR3 segments were identified. Patients who survived severe COVID-19 had significantly more of a Class 3 antibody (C135) to SARS-CoV-2 compared to non-survivors (15059.4 vs. 1412.7, p = 0.016). In addition to highlighting the utility of RNA sequencing in revealing unique NAb profiles in COVID-19 patients with different outcomes, we provided a physical basis for our findings via atomistic modeling combined with molecular dynamics simulations. We established the interactions of the Class 3 NAb C135 with the SARS-CoV-2 spike protein, proposing a mechanistic basis for inhibition via multiple conformations that can effectively prevent ACE2 from binding to the spike protein, despite C135 not directly blocking the ACE2 binding motif. Overall, we demonstrate that deep RNA sequencing combined with structural modeling offers the new potential to identify and understand novel therapeutic(s) NAbs in individuals lacking certain immune responses due to their poor endogenous production. Our results suggest a possible window of opportunity for administration of such NAbs when their full sequence becomes available. A method involving rapid deep RNA sequencing of patients infected with SARS-CoV-2 or its variants at the earliest infection time could help to develop personalized treatments using the identified specific NAbs.

Analysis of Serum IgG1 to Predict Progression and Therapeutic Effect in Patients with Multiple Myeloma

Objective

The correlation between laboratory indicators and clinical treatment effects and the prognosis of multiple myeloma remains poorly understood. Therefore, our study investigated whether serum IgG subclasses could be employed as potential indicators contributed to evaluate the therapeutic effect and prognosis of patients with multiple myeloma. Patients and Methods. Records of patients with multiple myeloma were initially diagnosed at the First Affiliated Hospital of Soochow University, China, from August 1, 2017, to February 28, 2020. The assessment abilities of serological indicators for therapeutic effect were evaluated in patients compared with healthy controls.

Results

In 560 study patients with multiple myeloma, serum IgA, IgG, IgM, κ-LC, and λ-LC increased by15%, 33.04%, 1.96%, 27.50%, and 26.43%, respectively. Further analysis found that IgG1, IgG2, IgG3, and IgG4 were over the upper limit of the reference range with 26.38%, 6.09%, 8.12%, and 4.64%, respectively. κ-LC and λ-LC were found in the urine in 65.13% and 29.70%, respectively. In peripheral blood, the proportion of CD3⁺CD4⁺, CD3⁻CD19⁺ cells, and CD4⁺/CD8⁺ decreased, whereas CD3⁺CD8⁺ cells and CD16⁺/CD56⁺ increased, and the associated cytokines IL-2, IL-4, IL-6, TNF-α, and IFN-γ were upregulated in patients when compared with healthy controls. Furthermore, the serum levels of IgA, IgG, IgG1, IgG2, IgG3, and IgG4 gradually decreased in patients before, during, and after treatment. Similar results were found in serum and urine κ-LC and λ-LC.

Conclusion

Serum IgG1 level could serve as the potential indicator for evaluating the therapeutic effect for patients with multiple myeloma. κ-LC and λ-LC also have the potential to be prognostic indicators. More studies are warranted to explore these serological indicators for personalized therapy in the future.

Deep Learning-Based CT Imaging in Diagnosing Myeloma and Its Prognosis Evaluation

Imaging examination plays an important role in the early diagnosis of myeloma. The study focused on the segmentation effects of deep learning-based models on CT images for myeloma, and the influence of different chemotherapy treatments on the prognosis of patients. Specifically, 186 patients with suspected myeloma were the research subjects. The U-Net model was adjusted to segment the CT images, and then, the Faster region convolutional neural network (RCNN) model was used to label the lesions. Patients were divided into bortezomib group (group 1, n = 128) and non-bortezomib group (group 2, n = 58). The biochemical indexes, blood routine indexes, and skeletal muscle of the two groups were compared before and after chemotherapy. The results showed that the improved U-Net model demonstrated good segmentation results, the Faster RCNN model can realize the labeling of the lesion area in the CT image, and the classification accuracy rate was as high as 99%. Compared with group 1, group 2 showed enlarged psoas major and erector spinae muscle after treatment and decreased bone marrow plasma cells content, blood M protein, urine 24 h light chain, pBNP, ß-2 microglobulin (β2MG), ALP, and white blood cell (WBC) levels (P < 0.05). In conclusion, deep learning is suggested in the segmentation and classification of CT images for myeloma, which can lift the detection accuracy. Two different chemotherapy regimens both improve the prognosis of patients, but the effects of non-bortezomib chemotherapy are better.

Cardiac amyloidosis with overt multiple myeloma presenting with pulmonary effusion: case report

Amyloidosis was initially described by Nicolaes Fonteyn in 1639. It is caused by the deposition of soluble immunoglobulin light chains as insoluble fibrils and can affect any organ including the heart, nervous system, dermis and subcutaneous tissue, kidneys and liver. This is a rare case of cardiac amyloidosis occurring with multiple myeloma and pleural effusion.

A 65-year-old Arab woman, nonsmoker, nonalcoholic, known to have hypothyroidism and multiple myeloma, presented to the hospital with dyspnea and basilar crackles. Workup was done to exclude leukemia. Cardiac echography showed features of amyloidosis.

Cardiac amyloidosis occurring with multiple myeloma and pleural effusion is rare. However, it is stated that 10–15% of amyloidosis patients might develop multiple myeloma (MM).

Kutane Manifestation einer AL-Amyloidose mit Plasmazellmyelom vom Lambda-Leichtkettentyp

Die mit einem multiplen Myelom assoziierte Immunoglobulin-Leichtketten (AL)-Amyloidose ist unter den systemischen Amyloidosen die häufigste Form, als Entität selbst jedoch relativ selten. Die durch den monoklonalen Plasmazellklon sezernierten instabilen Leichtketten führen als Amyloidablagerungen im Gewebe zu manifesten Organschäden, v. a. die renalen und kardialen Organmanifestationen führen häufig zu einer sehr schlechten Prognose. Besonders kutane Manifestationen wie beidseitige periorbitale Ödeme, Ekchymosen und eine Makroglossie können als pathognomonisch für die systemische AL-Amyloidose betrachtet werden und sollten zu einer raschen Abklärung führen. Wir berichten über einen Patienten mit einer kutanen Manifestation einer AL-Amyloidose mit assoziiertem „smouldering Myelom“.

Cutaneous Involvement in Plasma Cell Myeloma

OBJECTIVES

Plasma cell myeloma (PCM) involving skin is rare and occurs in 1% to 4% of patients with PCM. We evaluated the clinicopathologic features, cytogenetic findings and clinical follow-up in a series of PCM cases with cutaneous involvement.

METHODS

Cases of PCM with cutaneous involvement were retrospectively reviewed with clinical data.

RESULTS

Skin involvement in PCM occurred in older individuals (mean, 75 years) and was more frequent in men (7/10 patients). All cases showed bone marrow involvement preceding the cutaneous lesions. Histopathologically, the infiltrate was plasmacytic (n = 5) or primitive or plasmablastic (n = 4), and 1 case showed predominantly lymphoplasmacytic features with cyclin D1 immunoreactivity and CCND1 gene rearrangement. Concurrent amyloid deposition was seen in one biopsy, and another case demonstrated coexisting squamous cell carcinoma. The most common immunophenotype was CD138+, CD20-, and CD56+ with light chain restriction. Cytogenetic analysis (available for 7 cases) showed multiple hyperdiploid abnormalities. Follow-up was available for 8 cases (mean, 42 months; range, 11-156 months) and showed short-term disease-related death in 7 of 8 patients.

CONCLUSIONS

Cutaneous involvement in PCM demonstrates a diverse cytomorphologic spectrum with plasmacytic, plasmablastic, or lymphoplasmacytic features and may show concurrent amyloid deposition or neoplasms such as squamous cell carcinoma. Cutaneous involvement typically occurs late in the course of the disease and likely portends poor outcome.

Localized immunoglobulin light chain amyloidosis: Novel insights including prognostic factors for local progression

In localized light chain amyloidosis (locAL), amyloidogenic light chains (aLC) are produced and deposited locally by a B-cell clone. We present 293 patients with immunohistochemically confirmed locAL. Lung (nodular pulmonary) with 63 patients was the most involved organ. The aLC was λ in 217 cases (κ:λ ratio 1:3). A local B-cell clone was identified in 30% of cases. Sixty-one (21%) had a concomitant autoimmune disorder (cAD). A monoclonal component (MC) were present in 101 (34%) patients and were more frequent in subjects with cAD (51% vs 34%; P = .03). Cigarette smoking was more prevalent in lung locAL (54% vs 37%; P = .018). After a median follow-up of 44 months, 16 patients died and 5- and 10-years locAL progression-free survival (PFS) were 62% and 44%. Interestingly, locAL-PFS was shorter among patients with an identified clonal infiltrate at amyloid deposition site (40 vs 109 months; P = .02) and multinuclear giant cells and/or an inflammatory infiltrate resulted in longer locAL-PFS in lung involvement (65 vs 42 months; P = .01). However, no differences in locAL PFS were observed in patients with cAD, a MC and involved organ site. Treatment was administered in 163 (54%) patients and was surgical in 135 (46%). Median locAL-PFS after first treatment was 56 months. Responders had longer locAL-PFS (78 vs 17 months; P < .001). Three patients with lung locAL and a MC were diagnosed as systemic AL amyloidosis at follow-up. In summary, locAL pathogenesis seems to be heterogeneous and the clonal infiltrate leads local progression.