1
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Murphy BS, Liu A, Dendy JM, Johnson JE, Zalawadiya SK. A novel case report of isolated cardiac myxedematosus. Eur Heart J Case Rep 2024; 8:ytae430. [PMID: 39234275 PMCID: PMC11372473 DOI: 10.1093/ehjcr/ytae430] [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: 07/06/2023] [Revised: 10/06/2023] [Accepted: 08/13/2024] [Indexed: 09/06/2024]
Abstract
Background Cardiac mucinous deposits are a rare entity only previously described in the setting of scleromyxedema, a disorder characterized by cutaneous and systemic mucin deposits, fibroblastic proliferation, and monoclonal gammopathies. Case summary A 41-year-old woman was transferred to our hospital after a month-long hospitalization with worsening cardiogenic shock requiring ionotropic support. Cardiac magnetic resonance imaging revealed a left ventricular ejection fraction of 23%, prior right coronary artery infarct, full-thickness late gadolinium enhancement in the left ventricle basilar wall, global abnormal parametric mapping parameters of both native T1, T2, and extracellular volume, and severe biventricular dysfunction concerning for infiltrative cardiomyopathy. Endomyocardial biopsy demonstrated heavy deposits of interstitial mucin, confirmed by electron microscopy; a Congo red stain was negative for amyloid. She was treated with an aggressive decongestive strategy, oral guideline-directed medical therapy, and intravenous immunoglobulin (IVIg); she was discharged home off inotropic support. Subsequently, she had three additional hospitalizations for heart failure exacerbation in a span of 6 months, and her overall prognosis remains guarded. Discussion We report a first known case of isolated cardiac myxedematosus associated with a severe systolic and diastolic cardiomyopathy. Our patient did not have any clinical evidence of systemic scleromyxedema or paraproteinemia, both of which have been reported in association with cardiac mucin deposits. Mucinosus has been described in patients with systemic lupus erythematous; however, cardiac deposits have not been reported. While IVIg has been used as a treatment in previously reported cases of cardiac scleromyxedema, its clinical benefit remains unclear in isolated cardiac myxedematosus.
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Affiliation(s)
- Brittany Saldivar Murphy
- Department of Medicine, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, USA
| | - Angela Liu
- Department of Medicine, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, USA
| | - Jeffrey M Dendy
- Department of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joyce E Johnson
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandip K Zalawadiya
- Department of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
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2
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Mehta H, Bishnoi A, Singh C, Rajasekaran S, Chatterjee D, Kumaran MS, Handa S. A woman with leonine facies and monoclonal gammopathy. Clin Exp Dermatol 2024; 49:1094-1096. [PMID: 38619049 DOI: 10.1093/ced/llae136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/01/2024] [Accepted: 04/09/2024] [Indexed: 04/16/2024]
Abstract
A 32-year-old woman presented with a 3-year history of progressive skin thickening. On examination, the skin of the glabella was thickened with longitudinal furrows, resulting in leonine facies. Skin-coloured to reddish-brown, firm, waxy, closely spaced papules partially coalescing to form sheets of induration with circular punched-out areas of sparing in between over the face, neck, trunk, abdomen, arms and thighs were seen. She additionally complained of a tingling sensation and occasional pain over the lateral side of her hands. Punch biopsy obtained from a papule over the nape of the neck revealed fibroblast proliferation with collagen and mucin deposition in the upper and midreticular dermis.
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Affiliation(s)
- Hitaishi Mehta
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anuradha Bishnoi
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Charanpreet Singh
- Department of Clinical Hematology and Medical Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sangamitra Rajasekaran
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Debajyoti Chatterjee
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Muthu Sendhil Kumaran
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjeev Handa
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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3
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Liu SS, Park L, Karim R, Serralta V, Ciocca G, Susa JS, Hanly A, Karai LJ. Primary localized cutaneous lichen myxedematosus with light chain-restricted plasma cells: A distinct variant of the localized form of lichen myxedematosus. J Cutan Pathol 2024; 51:589-593. [PMID: 38699948 DOI: 10.1111/cup.14624] [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: 06/19/2023] [Revised: 02/23/2024] [Accepted: 04/03/2024] [Indexed: 05/05/2024]
Abstract
Lichen myxedematosus (LM) is a chronic cutaneous mucinosis that can present as a localized skin lesion or as a generalized systemic disease termed scleromyxedema. The differential diagnosis is determined by a combination of clinical presentation, serological studies, and histopathological examination. Currently, well-established and accepted histopathological features to distinguish localized LM from scleromyxedema have not been elucidated. Our recent publication, together with a retrospective literature review, suggests that the presence of groups of light chain-restricted plasma cells represents a distinct histopathological clue for the diagnosis of localized LM. In this report, we provide two additional cases of localized LM with lambda light chain-restricted plasma cells, together with clinical and histopathological findings that are similar to our previous publication. These cases support our theory that the light chain-restricted plasmacytic microenvironment is primarily attributed to the pathogenesis of localized LM. Therefore, we consider these cases to constitute a clinically and pathologically new variant of localized LM and name it primary localized cutaneous LM with light chain-restricted plasma cells.
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Affiliation(s)
- Shuo S Liu
- Department of Dermatology, Larkin Community Hospital, South Miami, Florida, USA
| | - Lily Park
- Department of Dermatology, Larkin Community Hospital, South Miami, Florida, USA
| | - Rehan Karim
- Department of Dermatology, Larkin Community Hospital, South Miami, Florida, USA
| | | | | | - Joseph S Susa
- Global Pathology, Sonic Healthcare USA, Miami Lakes, Florida, USA
| | - Andrew Hanly
- Global Pathology, Sonic Healthcare USA, Miami Lakes, Florida, USA
| | - Laszlo J Karai
- Department of Dermatology, Larkin Community Hospital, South Miami, Florida, USA
- Global Pathology, Sonic Healthcare USA, Miami Lakes, Florida, USA
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4
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Knobler R, Geroldinger-Simić M, Kreuter A, Hunzelmann N, Moinzadeh P, Rongioletti F, Denton C, Mouthon L, Cutolo M, Smith V, Gabrielli A, Bagot M, Olesen AB, Foeldvari I, Jalili A, Kähäri VM, Kárpáti S, Kofoed K, Olszewska M, Panelius J, Quaglino P, Seneschal J, Sticherling M, Sunderkötter C, Tanew A, Wolf P, Worm M, Skrok A, Rudnicka L, Krieg T. Consensus statement on the diagnosis and treatment of sclerosing diseases of the skin, Part 2: Scleromyxoedema and scleroedema. J Eur Acad Dermatol Venereol 2024; 38:1281-1299. [PMID: 38456518 DOI: 10.1111/jdv.19937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 02/06/2024] [Indexed: 03/09/2024]
Abstract
The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present consensus provides an update to the 2017 European Dermatology Forum Guidelines, focusing on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, updated strategies for the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 2 of this consensus provides clinicians with an overview of the diagnosis and treatment of scleromyxoedema and scleroedema (of Buschke).
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Affiliation(s)
- Robert Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Marija Geroldinger-Simić
- Department of Dermatology, Ordensklinikum Linz Elisabethinen, Linz, Austria
- Faculty of Medicine, Johannes Kepler University, Linz, Austria
| | - Alexander Kreuter
- Department of Dermatology, Venereology and Allergology, HELIOS St. Elisabeth Klinik Oberhausen, University Witten-Herdecke, Oberhausen, Germany
| | - Nicolas Hunzelmann
- Department of Dermatology and Venereology, University of Cologne, Cologne, Germany
| | - Pia Moinzadeh
- Department of Dermatology and Venereology, University of Cologne, Cologne, Germany
| | | | - Christopher Denton
- Center for Rheumatology, Royal Free and University College Medical School, London, UK
| | - Luc Mouthon
- Service de Médecine Interne, Centre de Référence Maladies Auto-Immunes et Systémiques Rares d'Ile de France, APHP-CUP, Hôpital Cochin, Paris, France
- Institut Cochin, Université de Paris Cité, Paris, France
| | - Maurizio Cutolo
- Laboratories for Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine DiMI, University Medical School of Genoa, IRCCS San Martino Genoa, Genova, Italy
| | - Vanessa Smith
- Department of Internal Medicine, Ghent University, Ghent, Belgium
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
- Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Ghent, Belgium
| | - Armando Gabrielli
- Fondazione di Medicina Molecolare e Terapia Cellulare, Università Politecnica delle Marche, Ancona, Italy
| | - Martine Bagot
- Department of Dermatology, Hôpital Saint-Louis, Université Paris Cité, Paris, France
| | - Anne B Olesen
- Department of Dermatology, University Hospital of Aarhus, Aarhus, Denmark
| | - Ivan Foeldvari
- Hamburg Centre for Pediatric and Adolescent Rheumatology, Schön Klinik Hamburg Eilbek, Hamburg, Germany
| | - Ahmad Jalili
- Department of Dermatology, Dermatology & Skin Care Clinic, Buochs, Switzerland
| | - Veli Matti Kähäri
- Department of Dermatology and Venereology, University of Turku and Turku University Hospital, Turku, Finland
| | - Sarolta Kárpáti
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - Kristian Kofoed
- The Skin Clinic, Department of Dermato-Allergology, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Jaana Panelius
- Department of Dermatology and Allergology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pietro Quaglino
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Julien Seneschal
- Department of Dermatology and Pediatric Dermatology, National Centre for Rare Skin Disorders, Hôpital Saint-Andre, University of Bordeaux, CNRS, Immuno CencEpT UMR 5164, Bordeaux, France
| | | | - Cord Sunderkötter
- Department of Dermatology and Venereology, University Hospital Halle, Halle (Saale), Germany
| | - Adrian Tanew
- Private Practice, Medical University of Vienna, Vienna, Austria
| | - Peter Wolf
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology, Venereology and Allergology, University Hospital Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Skrok
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - Lidia Rudnicka
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - Thomas Krieg
- Department of Dermatology and Venereology, and Translational Matrix Biology, University of Cologne, Cologne, Germany
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5
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Fasano G, Valenti G, D’Amico D, Valenti M. Combination of intravenous immunoglobulin, oral prednisone, and methotrexate for managing scleromyxedema: case report and literature discussion. Dermatol Reports 2024; 16:9803. [PMID: 38957635 PMCID: PMC11216142 DOI: 10.4081/dr.2023.9803] [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: 07/16/2023] [Accepted: 07/23/2023] [Indexed: 07/04/2024] Open
Abstract
The generalized and sclerodermic form of lichen myxedematosus, known as scleromyxedema (SMX), is a chronic mucinosis that manifests cutaneously and has multiple systemic comorbidities. There are few available treatment options and no established therapeutic guidelines. We describe a 48-year-old man who had intravenous immunoglobulins (IVIg), oral corticosteroids, and methotrexate (MTX) for the treatment of SMX, monoclonal gammopathy, and arthritis. Because of its effectiveness and high level of tolerance, IVIg is the most often used first-line therapy for SMX and has been used for an increasing range of skin conditions. In our instance, better control of skin disease and extracutaneous manifestations was made possible by combining IVIg with oral prednisone and MTX. To the best of our knowledge, this is the first instance of SMX treatment that has combined therapeutic approaches with a favorable safety profile.
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Affiliation(s)
- Gaia Fasano
- Department of Health Sciences, Magna Graecia University, Catanzaro
| | | | - Domenico D’Amico
- Dermatology Unit, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro
| | - Mario Valenti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI)
- Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
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6
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Peshin S, Modi SK, Burwick N. Lenalidomide and Dexamethasone in Scleromyxedema: A Case Report of Long-Term Efficacy and Challenges in a 54-Year-Old Patient. Cureus 2024; 16:e63181. [PMID: 39070368 PMCID: PMC11281881 DOI: 10.7759/cureus.63181] [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: 06/26/2024] [Indexed: 07/30/2024] Open
Abstract
Lichen myxedematosus (LM) is characterized by dermal mucin buildup, fibroblast proliferation, and variable presentation. The diffuse variant, known as scleromyxedema, is identified by monoclonal paraprotein presence and lack of thyroid issues, with considerations for infections and underlying conditions. Despite lacking FDA-approved treatment, intravenous immunoglobulin stands as effective, although resource-intensive, while targeting the clonal source of pathogenic immunoglobulin offers an alternate therapeutic route. Our case explores the efficacy of an oral plasma cell-focused lenalidomide regimen, inducing relief and treatment-free periods, while still facing relapses. However, this approach poses risks, necessitating a comparative safety and efficacy assessment. Data remains insufficient to establish the prolonged efficacy of plasma cell-targeted therapy versus alternatives for monoclonal gammopathy of undetermined significance-associated scleromyxedema. We present the case of a 54-year-old male patient diagnosed with LM managed for six years with relapsing and remitting symptoms.
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Affiliation(s)
- Supriya Peshin
- Internal Medicine, Norton Community Hospital, Norton, USA
| | - Shivani K Modi
- Internal Medicine, Einstein Medical Center Philadelphia, Norristown, USA
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7
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Sunderkötter C, Bruns T, Pfeiffer C. [Scleromyxedema]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2024; 75:225-231. [PMID: 38363313 DOI: 10.1007/s00105-024-05303-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/17/2024]
Abstract
Scleromyxedema or generalized diffuse lichen myxoedematosus is a rare mucinosis that is associated with monoclonal gammopathy and which frequently affects multiple extracutaneous organ systems. The pathogenesis of scleromyxedema has not been fully elucidated, but includes stimulation of glycosaminoglycan synthesis. The clinical course of scleromyxedema is chronic and often progressive, leading to severe morbidity and even death. The characteristic skin findings encompass multiple waxy papules often on indurated plaques, while thickening of skin leads to conspicuous folds on glabella and dorsal aspects of finger joints. Microscopical manifestations are dermal deposits of glycosaminoglycans between collagen bundles in reticular dermis, increased numbers of fibroblasts and fibrosis as well as loss of elastic fibers. Progressive skin involvement results in decreased mobility of the mouth and joints and even contractures. Extracutaneous manifestations occur in the musculoskeletal or cardiovascular system, in the gastrointestinal or respiratory tract, in the kidneys or in the central and peripheral nervous system. There are no in-label or evidence-based treatments available for scleromyxedema, but by expert consensus high-dose immunoglobulins are considered as treatment of choice, followed in case of insufficient efficacy by systemic glucocorticosteroids and then lenalidomide or thalidomide. In severe and refractory cases, autologous hematopoietic stem cell transplantation has been performed. Long-term maintenance treatment is usually required to prevent recurrences. Close interdisciplinary follow-up is recommended.
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Affiliation(s)
- Cord Sunderkötter
- Abteilung für translationale Dermatoinfektiologie, Westfälische Wilhelms-Universität Münster, Münster, Deutschland.
- Universitätsklinik und Poliklinik für Dermatologie und Venerologie, Universitätsmedizin Halle (Saale), Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland.
| | - Tom Bruns
- Universitätsklinik und Poliklinik für Dermatologie und Venerologie, Universitätsmedizin Halle (Saale), Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland
| | - Christiane Pfeiffer
- Klinik und Poliklinik für Dermatologie und Allergologie, LMU Klinikum - Campus Innenstadt, München, Deutschland
- Klinik für Dermatologie, München Klinik, München, Deutschland
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8
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Agrawal S, Leung N, Drage L. Scleromyxedema and Underlying Multiple Myeloma. Mayo Clin Proc 2024; 99:283-284. [PMID: 38309938 DOI: 10.1016/j.mayocp.2023.08.022] [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] [Received: 07/24/2023] [Revised: 08/10/2023] [Accepted: 08/23/2023] [Indexed: 02/05/2024]
Affiliation(s)
- Shruti Agrawal
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA; Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Lisa Drage
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
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9
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Burzi L, Rosset F, Senetta R, Conti L, Mastorino L, Dapavo P, Quaglino P, Ribero S. Rare scleromyxedema granuloma-annulare-like pattern successfully treated with intravenous immunoglobulins. Ital J Dermatol Venerol 2024; 159:80-81. [PMID: 38226941 DOI: 10.23736/s2784-8671.23.07816-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Affiliation(s)
- Lorenza Burzi
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Francois Rosset
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy -
| | - Rebecca Senetta
- Department of Medical Sciences, Pathology Clinic, University of Turin, Turin, Italy
| | - Luca Conti
- Department of Medical Sciences, Pathology Clinic, University of Turin, Turin, Italy
| | - Luca Mastorino
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Paolo Dapavo
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Pietro Quaglino
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
| | - Simone Ribero
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Turin, Italy
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10
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Zhang D, Sable K, Miller A, Hinshaw M, Schmidt T, Shields BE. Granulomatous variant of scleromyxedema successfully treated with topical ruxolitinib, dapsone and intravenous immunoglobulin. JAAD Case Rep 2023; 42:78-83. [PMID: 38156097 PMCID: PMC10753040 DOI: 10.1016/j.jdcr.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023] Open
Affiliation(s)
- Donglin Zhang
- Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kimberly Sable
- Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Allison Miller
- Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Molly Hinshaw
- Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Timothy Schmidt
- Department of Hematology and Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Bridget E. Shields
- Department of Dermatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Chen J, Zhang X, Li Q, Liu M, Fu Z. Generalized Muscular Uptake of 99mTc-MDP on Bone Scan in a Patient With Scleromyxedema-Associated Myopathy. Clin Nucl Med 2023; Publish Ahead of Print:00003072-990000000-00566. [PMID: 37220249 DOI: 10.1097/rlu.0000000000004712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
ABSTRACT A 62-year-old man presented with a 5-year history of progressive myasthenia, myalgia, and skin changes. Upon laboratory testing, elevated serum creatine kinase and lactate dehydrogenase, as well as monoclonal immunoglobulin Gκ, were observed. A bone scan revealed generalized muscular uptake of 99mTc-MDP, whereas 18F-FDG PET/CT demonstrated only mild hypermetabolism of the muscles. A muscle biopsy showed myofibrillary vacuolar degeneration, and a skin biopsy indicated scleromyxedema. Based on these findings, the patient was diagnosed with scleromyxedema-associated myopathy.
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Affiliation(s)
- Jinzhi Chen
- From the Department of Nuclear Medicine, Peking University First Hospital, Beijing
| | - Xi Zhang
- From the Department of Nuclear Medicine, Peking University First Hospital, Beijing
| | - Qian Li
- Department of Ultrasound, Shenzhen University General Hospital, Shenzhen, China
| | - Meng Liu
- From the Department of Nuclear Medicine, Peking University First Hospital, Beijing
| | - Zhanli Fu
- From the Department of Nuclear Medicine, Peking University First Hospital, Beijing
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12
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Kaur J, Valisekka SS, Hameed M, Bandi PS, Varma S, Onwughalu CJ, Ibrahim H, Mongia H. Monoclonal Gammopathy of Undetermined Significance: A Comprehensive Review. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:e195-e212. [PMID: 36966041 DOI: 10.1016/j.clml.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/13/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023]
Abstract
Monoclonal Gammopathy of Undetermined Significance (MGUS) is an asymptomatic premalignant plasma cell dyscrasia with a predominate rise of the IgG immunoglobulin fraction without end-organ damage, often diagnosed incidentally. Despite its progression into various subsequent forms of hematological malignancies, MGUS remains underdiagnosed. A literature search was conducted using the Medline, Cochrane, Embase, and Google Scholar databases, including articles published until December 2022. Keywords used encompassed "Monoclonal Gammopathy of Undetermined Significance," "Plasma Cell dyscrasia," "Monoclonal gammopathy of renal significance," and "IgM Monoclonal gammopathy of Undetermined Significance," This study aimed to conduct a critical review to update knowledge regarding the pathophysiology, risk factors, clinical features, diagnostic protocols, complications, and current and novel treatments for MGUS. We recommend a multidisciplinary approach to manage MGUS due to the complexity of the illness's etiology, diagnosis, and therapy. This comprehensive review also highlights future prospects, such as developing screening protocols for at-risk populations, prevention of disease progression by early diagnosis through genome-wide association studies, and management using Daratumumab and NSAIDs.
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Affiliation(s)
- Jasneet Kaur
- Internal Medicine, Nassau University Medical Center, East Meadow, New York, USA..
| | | | - Maha Hameed
- Internal Medicine, Florida State University/Sarasota Memorial Hospital, Sarasota, Florida, USA.
| | | | | | | | - Hany Ibrahim
- Ain Shams University, Faculty of Medicine, Cairo, Egypt.
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13
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Wang SS, Chen QY, Xiang LH. Case report: Scleromyxedema associated with a monoclonal gammapathy: Successful treatment with intravenous immunoglobulins. Front Immunol 2023; 13:1099918. [PMID: 36713453 PMCID: PMC9880447 DOI: 10.3389/fimmu.2022.1099918] [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] [Received: 11/16/2022] [Accepted: 12/21/2022] [Indexed: 01/15/2023] Open
Abstract
Scleromyxedema is a rare idiopathic fibromucinous disorder characterized by a generalized papular and sclerodermoid cutaneous eruption. Patients often have praraproteinemia and extracutaneous, even lethal, manifestations. Yet the prognostic and therapeutic features of scleromyxedema are poorly documented. High-dose intravenous immunoglobulin (IVIG), used either alone or in conjunction with systemic steroids and/or thalidomide, has been suggested as a first-line treatment. We report the case of a 45-year-old woman diagnosed with scleromyxedema with paraproteinemia that initially did not respond to systemic steroids, retinoids, and thalidomide but greatly improvement in terms of systemic and cutaneous symptoms after treatment with IVIG.
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14
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Dermatological manifestations of hematologic neoplasms. Part II: nonspecific skin lesions/paraneoplastic diseases. An Bras Dermatol 2023; 98:141-158. [PMID: 36682966 PMCID: PMC9984718 DOI: 10.1016/j.abd.2022.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/22/2022] [Accepted: 08/09/2022] [Indexed: 01/21/2023] Open
Abstract
Cutaneous manifestations occur in the course of hematologic malignancies and precede, accompany or occur late in relation to the diagnosis. They result from paraneoplastic phenomena, tumor infiltrations, immunosuppression resulting from the hematologic disease itself or its treatment. The dermatologist must be aware of these conditions that may be helpful both in the diagnosis of the underlying disease and in reducing patient morbidity. This review (part II) addresses the paraneoplastic dermatological changes associated with systemic hematologic malignancies.
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15
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GALLO R, TRAVE I, COTZIA E, RUSSO R, PARODI A. Dermato-neuro Syndrome after COVID-19 Vaccination in a Patient with Scleromyxoedema Previously Controlled with Bortezomib and Intravenous Immunoglobulins. Acta Derm Venereol 2022; 102:adv00836. [PMID: 36511333 PMCID: PMC9811295 DOI: 10.2340/actadv.v102.4430] [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] [Indexed: 12/15/2022] Open
Abstract
Abstract is missing (Short communication)
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Affiliation(s)
- Rosella GALLO
- Section of Dermatology – Department of Health Sciences, University of Genoa, IRCCS – Ospedale Policlinico San Martino, Genoa
| | - Ilaria TRAVE
- Section of Dermatology – Department of Health Sciences, University of Genoa, IRCCS – Ospedale Policlinico San Martino, Genoa
| | - Emilia COTZIA
- Section of Hematology, Ospedale E. Muscatello-Augusta, Siracusa, Italy
| | - Roberto RUSSO
- Section of Dermatology – Department of Health Sciences, University of Genoa, IRCCS – Ospedale Policlinico San Martino, Genoa
| | - Aurora PARODI
- Section of Dermatology – Department of Health Sciences, University of Genoa, IRCCS – Ospedale Policlinico San Martino, Genoa
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16
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Muacevic A, Adler JR, Berumen-Glinz C, Quijada-Ucelo Z, Hernandez-Ramirez H, De Anda-Juárez M, Vega-Memije E. Combination of Medical and Surgical Treatment in Scleromyxedema. Cureus 2022; 14:e32729. [PMID: 36686085 PMCID: PMC9850859 DOI: 10.7759/cureus.32729] [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: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
Scleromyxedema is an uncommon and progressive fibromucinous disorder characterized by disseminated papular eruption with histological features of dermal mucin deposition. The skin changes associated with this disease are highly visible and they tend to affect the patient's quality of life. We report a case of a 50-year-old male patient that presented a 3-year-old history of disseminated asymptomatic firm papules-associated systemic symptoms. Medical treatment with oral corticosteroid and thalidomide was indicated and surgical treatment on residual facial folds was performed, with an excellent outcome.
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17
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Oganesyan A, Gregory A, Malard F, Ghahramanyan N, Mohty M, Kazandjian D, Mekinian A, Hakobyan Y. Monoclonal gammopathies of clinical significance (MGCS): In pursuit of optimal treatment. Front Immunol 2022; 13:1045002. [PMID: 36505449 PMCID: PMC9728929 DOI: 10.3389/fimmu.2022.1045002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
Monoclonal gammopathy of clinical significance (MGCS) represents a new clinical entity referring to a myriad of pathological conditions associated with the monoclonal gammopathy of undetermined significance (MGUS). The establishment of MGCS expands our current understanding of the pathophysiology of a range of diseases, in which the M protein is often found. Aside from the kidney, the three main organ systems most affected by monoclonal gammopathy include the peripheral nervous system, skin, and eye. The optimal management of these MGUS-related conditions is not known yet due to the paucity of clinical data, the rarity of some syndromes, and limited awareness among healthcare professionals. Currently, two main treatment approaches exist. The first one resembles the now-established therapeutic strategy for monoclonal gammopathy of renal significance (MGRS), in which chemotherapy with anti-myeloma agents is used to target clonal lesion that is thought to be the culprit of the complex clinical presentation. The second approach includes various systemic immunomodulatory or immunosuppressive options, including intravenous immunoglobulins, corticosteroids, or biological agents. Although some conditions of the MGCS spectrum can be effectively managed with therapies aiming at the etiology or pathogenesis of the disease, evidence regarding other pathologies is severely limited to individual patient data from case reports or series. Future research should pursue filling the gap in knowledge and finding the optimal treatment for this novel clinical category.
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Affiliation(s)
- Artem Oganesyan
- Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia,Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia,*Correspondence: Artem Oganesyan,
| | - Andrew Gregory
- Wayne State University School of Medicine, Detroit, MI, United States
| | - Florent Malard
- Department of Clinical Hematology and Cellular Therapy, INSERM, Saint-Antoine Research Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
| | - Nerses Ghahramanyan
- Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, INSERM, Saint-Antoine Research Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
| | - Dickran Kazandjian
- Myeloma Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, United States
| | - Arsène Mekinian
- Department of Internal Medicine (DMU i3), Sorbonne University, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France,French-Armenian Clinical Research Center, National Institute of Health, Yerevan, Armenia
| | - Yervand Hakobyan
- Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia,Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia
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18
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Henrie R, Cherniawsky H, Marcon K, Zhao EJ, Marinkovic A, Pourshahnazari P, Parkin S, Chen LYC. Inflammatory diseases in hematology: a review. Am J Physiol Cell Physiol 2022; 323:C1121-C1136. [PMID: 35938681 DOI: 10.1152/ajpcell.00356.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Hematopoietic cells are instrumental in generating and propagating protective inflammatory responses to infection or injury. However, excessive inflammation contributes to many diseases of the blood, bone marrow, and lymphatic system. We review three clinical categories of hematological inflammatory diseases in which recent clinical and translational advances have been made. The first category are monogenic inflammatory diseases. Genotype-driven research has revealed that previously mysterious diseases with protean manifestations are characterized by mutations which may be germline (e.g. deficiency of ADA2 or GATA2 deficiency) or somatic (e.g. VEXAS syndrome). The second category are the cytokine storm syndromes, including hemophagocytic lymphohistiocytosis and Castleman disease. Cytokine storm syndromes are characterized by excessive production of inflammatory cytokines including interleukin-6 and interferon-gamma, causing end-organ damage and high mortality. Finally, we review disorders associated with monoclonal and polyclonal hypergammaglobulinemia. The serum protein electrophoresis (SPEP) is typically ordered to screen for common diseases such as myeloma and humoral immunodeficiency. However, monoclonal and polyclonal hypergammaglobulinemia on SPEP can also provide important information in rare inflammatory diseases. For example, the autoinflammatory disease Schnitzler syndrome is notoriously difficult to diagnose. While this orphan disease has eluded precise genetic or histological characterization, the presence of a monoclonal paraprotein, typically IgM, is an obligate diagnostic criterion. Likewise, polyclonal hypergammaglobulinemia may be an important early, non-invasive diagnostic clue for patients presenting with rare neoplastic diseases such as Rosai-Dorfman disease and angioimmunoblastic T-cell lymphoma. Applying these three categories to patients with unexplained inflammatory syndromes can facilitate the diagnosis of rare and under-recognized diseases.
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Affiliation(s)
- Ryan Henrie
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Hannah Cherniawsky
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Krista Marcon
- Division of Hematopathology, Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Eric J Zhao
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Angelina Marinkovic
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Persia Pourshahnazari
- Division of Allergy and Immunology, Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Stephen Parkin
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Luke Y C Chen
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.,Centre for Health Education Scholarship, University of British Columbia, Vancouver, BC, Canada
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19
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Marinkovic A, Zypchen LN, Chan J, Chen LY, Parkin S. Monoclonal gammopathy of clinical significance: what the rheumatologist needs to know. THE LANCET. RHEUMATOLOGY 2022; 4:e362-e373. [PMID: 38294033 DOI: 10.1016/s2665-9913(21)00348-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/29/2021] [Accepted: 10/18/2021] [Indexed: 02/01/2024]
Abstract
Monoclonal proteins can provide important information on the diagnosis of several non-malignant systemic inflammatory disorders. At low concentration, they most commonly represent monoclonal gammopathy of undetermined significance (MGUS), whereas high concentrations often signify plasma cell myeloma or B-cell lymphoma. However, several rare inflammatory conditions associated with variable concentrations of monoclonal proteins, systemic symptoms, and organ dysfunction also exist. These conditions are termed monoclonal gammopathies of clinical significance (MGCS). Patients with MGCS might present to rheumatologists with undiagnosed systemic inflammatory disorders and the monoclonal protein provides an important, underappreciated clue for diagnosis. In this Review, we provide an approach to distinguishing MGCS from MGUS and lymphoid neoplasms, focusing on four rare MGCS that rheumatologists must recognise: scleromyxedema, Schnitzler's syndrome, idiopathic systemic capillary leak syndrome (also known as Clarkson's disease), and telangiectasias, elevated erythropoietin and erythrocytosis, monoclonal gammopathy, perinephric fluid collections, and intrapulmonary shunting (known as TEMPI) syndrome.
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Affiliation(s)
- Angelina Marinkovic
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Leslie N Zypchen
- Division of Hematology, University of British Columbia, Vancouver, BC, Canada
| | - Jonathan Chan
- Division of Rheumatology, University of British Columbia, Vancouver, BC, Canada
| | - Luke Yc Chen
- Division of Hematology, University of British Columbia, Vancouver, BC, Canada; Centre for Health Education Scholarship, University of British Columbia, Vancouver, BC, Canada
| | - Stephen Parkin
- Division of Hematology, University of British Columbia, Vancouver, BC, Canada; Vancouver General Hospital, Vancouver, BC, Canada.
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20
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Cutaneous manifestations of monoclonal gammopathy. Blood Cancer J 2022; 12:58. [PMID: 35411042 PMCID: PMC9001632 DOI: 10.1038/s41408-022-00661-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/17/2022] [Accepted: 02/23/2022] [Indexed: 12/29/2022] Open
Abstract
Monoclonal gammopathy associated with dermatological manifestations are a well-recognized complication. These skin disorders can be associated with infiltration and proliferation of a malignant plasma cells or by a deposition of the monoclonal immunoglobulin in a nonmalignant monoclonal gammopathy. These disorders include POEMS syndrome, light chain amyloidosis, Schnitzler syndrome, scleromyxedema and TEMPI syndrome. This article provides a review of clinical manifestations, diagnostics criteria, natural evolution, pathogenesis, and treatment of these cutaneous manifestations.
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21
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Fritz M, Tinker D, Wessel AW, Morris GM, Goldenberg L, Fesler M, Rukmangadachar L, Hurley MY. SARS-CoV-2: A potential trigger of dermato-neuro syndrome in a patient with scleromyxedema. JAAD Case Rep 2021; 18:99-102. [PMID: 34778497 PMCID: PMC8571101 DOI: 10.1016/j.jdcr.2021.10.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Mike Fritz
- University of Kentucky College of Medicine, Lexington, Kentucky
| | - Daniel Tinker
- Department of Dermatology, Saint Louis University, St. Louis, Missouri
| | - Alex W Wessel
- Washington University School of Medicine, St. Louis, Missouri
| | - Gabriela M Morris
- Department of Dermatology, Saint Louis University, St. Louis, Missouri
| | - Linda Goldenberg
- Division of Hematology, Oncology, & Cellular Therapy, Department of Internal Medicine, Saint Louis University, St. Louis, Missouri
| | - Mark Fesler
- Division of Hematology, Oncology, & Cellular Therapy, Department of Internal Medicine, Saint Louis University, St. Louis, Missouri
| | | | - M Yadira Hurley
- Department of Dermatology, Saint Louis University, St. Louis, Missouri
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22
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Treatment of Patients with Monoclonal Gammopathy of Clinical Significance. Cancers (Basel) 2021; 13:cancers13205131. [PMID: 34680279 PMCID: PMC8533809 DOI: 10.3390/cancers13205131] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/29/2021] [Accepted: 10/08/2021] [Indexed: 12/17/2022] Open
Abstract
Simple Summary Monoclonal gammopathy of clinical significance (MGCS) is a recently recognized clinical-pathological entity. Symptoms are caused by the presence of a monoclonal protein leading to high comorbidity. The affected organs vary according to the target antigen However, as most of the knowledge relies on case reports or short series; there is a lack of consensus regarding treatment approach. Here, we discuss MGCS other than renal (skin, ocular, neurologic, and bleeding disorders). We provide insights into the pathophysiology, diagnosis, treatment, and follow-up based on clinical cases. Finally, we discuss future directions in this field, such as potential novel therapeutic targets and prognosis of patients with MGCS. Abstract Monoclonal gammopathy of undetermined significance (MGUS) is defined as the presence of a monoclonal protein (M-protein) produced by a small amount of plasma cells. The majority of patients remain asymptomatic; however, a fraction of them develop clinical manifestations related to the monoclonal gammopathy despite not fulfilling criteria of multiple myeloma or other lymphoproliferative disorder. These patients constitute an emerging clinical issue coined as monoclonal gammopathy of clinical significance (MGCS). The mechanisms involved are poorly understood, and literature is scarce regarding management. The clinical spectrum involves symptoms related to renal, neurologic, skin, ocular, or bleeding manifestations, requiring a multidisciplinary approach. Treatment strategies rely on the basis of symptomatic disease and the M-protein isotype. In this review, we focus on MGCS other than renal, as the latter was earliest recognized and better known. We review the literature and discuss management from diagnosis to treatment based on illustrative cases from daily practice.
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23
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Maguire CA, Philippidou M, Schey S, Basu TN, Pembroke AC. Widespread, waxy, coalescing cutaneous papules. Clin Exp Dermatol 2021; 46:1626-1628. [PMID: 34490932 DOI: 10.1111/ced.14659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2021] [Indexed: 11/29/2022]
Affiliation(s)
- C A Maguire
- Departments of Dermatology, King's College Hospital NHS Foundation Trust, London, UK
| | - M Philippidou
- Histopathology, King's College Hospital NHS Foundation Trust, London, UK
| | - S Schey
- Haematology, King's College Hospital NHS Foundation Trust, London, UK
| | - T N Basu
- Departments of Dermatology, King's College Hospital NHS Foundation Trust, London, UK.,Haematology, King's College Hospital NHS Foundation Trust, London, UK
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24
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Ugur MC, Gediz F. Evaluation of patients diagnosed with psoriasis and multiple myeloma after autologous stem cell transplantation. Transfus Apher Sci 2021; 60:103137. [PMID: 33858753 DOI: 10.1016/j.transci.2021.103137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 03/31/2021] [Accepted: 04/06/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The secretion of monoclonal immunoglobulins increase in chronic inflammatory disorders such as chronic infections and autoimmune diseases. This risk is further increased by the biological agents used in the treatment of autoimmune diseases such as psoriasis. Hematological malignancies occurring in patients with psoriasis provides an opportunity to evaluate the effect of autologous or allogeneic stem cell transplantation in this immune-mediated disease. CASES Four patients diagnosed with psoriasis are presented, having undergone autologous bone marrow transplantation (ABMT), and eventually having remission of their psoriasis, after developing multiple myeloma during follow up. Psoriasis history of the patients was 20, 23, 2 and 2 years, respectively. All of them received peroral methotrexate or topical corticosteroid therapy. Time until myeloma diagnosis were 220, 144, 25, 18 months and follow-up after ABMT were 26, 19, 15, 22 months, respectively CONCLUSION: Psoriasis can be effectively treated with stem cell transplantation that is used in the treatment of malignancies. For this reason, stem cell transplantation can be considered as a treatment option in these patients, considering the benefit-to-harm ratio. However, uncertainty continues regarding the autologous or allogeneic application of stem cell transplantation.
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Affiliation(s)
- Mehmet Can Ugur
- University of Health Sciences, Bozyaka Education and Traing Hospital, Department of Hematology, Izmir, Turkey.
| | - Füsun Gediz
- University of Health Sciences, Bozyaka Education and Traing Hospital, Department of Hematology, Izmir, Turkey
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25
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Hoffmann JHO, Enk AH. Skleromyxödem. J Dtsch Dermatol Ges 2020; 18:1449-1468. [PMID: 33373121 DOI: 10.1111/ddg.14319_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/10/2020] [Indexed: 11/30/2022]
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26
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Hoffmann JHO, Enk AH. Scleromyxedema. J Dtsch Dermatol Ges 2020; 18:1449-1467. [PMID: 33373143 DOI: 10.1111/ddg.14319] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/10/2020] [Indexed: 11/29/2022]
Abstract
Scleromyxedema is a rare, cutaneous deposition disorder from the group of mucinoses, which can affect multiple organs and is virtually always associated with a monoclonal gammopathy. Cutaneous manifestations are usually generalized, 2 to 3 mm sized, dome-shaped or flat-topped, waxy, slightly red to skin-colored papules and sclerodermoid indurations. Neurological, rheumatological, cardiovascular, gastrointestinal, respiratory tract, renal and ophthalmologic manifestations can occur, with decreasing frequency. A serious and potentially lethal complication is the dermato-neuro syndrome which manifests with flu-like prodromes followed by fever, convulsions and coma. Untreated, scleromyxedema usually takes an unpredictable and potentially lethal progressive disease course over several years. According to a widely acknowledged classification by Rongioletti a diagnosis of scleromyxedema can be rendered when (1) generalized, papular and sclerodermoid eruption, (2) a histological triad of mucin deposition, fibroblast proliferation and fibrosis, and (3) monoclonal gammopathy are present, and (4) thyroid disease is absent. Apart from the classic microscopic triad, an interstitial granuloma annulare like pattern was also described. The pathogenesis of scleromyxedema is unknown. A potential role for various, as yet unknown serum factors has been discussed. An unequivocal causal relationship between paraproteinemia and disease manifestations could not be established to date. High dose intravenous immunoglobulins (IVIg) are the first-line treatment of choice according to the most recent European guidelines.
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Affiliation(s)
| | - Alexander H Enk
- Department of Dermatology, University of Heidelberg, Germany
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27
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Larios JM, Ciuro J, Sam Varghese T, Lyons SE. Successful treatment of dermato-neuro syndrome with plasmapheresis. BMJ Case Rep 2020; 13:13/12/e237170. [PMID: 33376089 PMCID: PMC7778741 DOI: 10.1136/bcr-2020-237170] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Altered mental status can have many causes ranging from emergent intracranial pathologies to more insidious, systemic toxic aetiologies. We report a rare case of dermato-neuro syndrome in a 71-year-old man with a known history of scleromyxoedema. The patient initially presented with encephalopathy which quickly progressed to generalised tonic-clonic seizures and coma. While his presentation fits with other, although rare, cases of dermato-neuro syndrome, it is imperative to rule out lethal, more common causes of altered mentation. Due to the rarity and difficulty in diagnosis of dermato-neuro syndrome, there is a significant debate regarding the optimal management as there are no standardised treatment protocols. In our case, the patient was successfully treated with plasmapheresis resulting in improved neurologic function.
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Affiliation(s)
- Jose Maciel Larios
- Department of Internal Medicine, Providence-Providence Park Hospital, Southfield, Michigan, USA
| | - Jordan Ciuro
- Department of Internal Medicine, Providence-Providence Park Hospital, Southfield, Michigan, USA
| | - Thomson Sam Varghese
- Department of Internal Medicine, Providence-Providence Park Hospital, Southfield, Michigan, USA
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28
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Win H, Gowin K. Treatment of scleromyxedema with lenalidomide, bortezomib and dexamethasone: A case report and review of the literature. Clin Case Rep 2020; 8:3043-3049. [PMID: 33363876 PMCID: PMC7752349 DOI: 10.1002/ccr3.3302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/28/2020] [Accepted: 08/12/2020] [Indexed: 11/16/2022] Open
Abstract
Scleromyxedema is a rare and progressive disease that currently has no standard treatment. Triplet therapy with lenalidomide, bortezomib, and dexamethasone can be an effective therapy for scleromyxedema, especially in patients with refractory or relapsed disease.
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Affiliation(s)
- Hninyee Win
- Department of MedicineUniversity of ArizonaTucsonArizona
| | - Krisstina Gowin
- Department of Hematology and OncologyUniversity of ArizonaTucsonArizona
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29
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Khandkar C, Vaidya K, Penglase R, Cai K, Shin JS, Hunyor I, Keech A, McGill N. Rare case of infiltrative cardiomyopathy secondary to scleromyxoedema. Intern Med J 2020; 50:127-128. [PMID: 31943623 DOI: 10.1111/imj.14695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/08/2019] [Accepted: 08/06/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Chinmay Khandkar
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kaivan Vaidya
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Ross Penglase
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Ken Cai
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Joo-Shik Shin
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Imre Hunyor
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Keech
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia.,National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, New South Wales, Australia
| | - Neil McGill
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
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30
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Abstract
Acral persistent papular mucinosis (APPM) is a subtype of localized lichen myxedematosus (LM) characterized by the chronic development of white to skin-colored papules and limited to the extensor surfaces of the hands and distal part of forearms, in the absence of systemic or laboratory manifestations. There is a strong predominance in women. Histopathology shows focal accumulation of mucin in the upper portion of the dermis sparing the grenz zone. The etiology is unknown. It is a benign condition, although dynamic changes occur with the progressive development of additional lesions. No specific treatment is required, and patients should be reassured about the prognosis.
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Affiliation(s)
- Franco Rongioletti
- Dermatology Clinic, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Caterina Ferreli
- Dermatology Clinic, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Laura Atzori
- Dermatology Clinic, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
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31
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Fonseca Aizpuru EM, Delgado Verges C, González García E, Barcala Vázquez L. Escleromixedema, Presentación de 2 Nuevos Casos y Revisión de la Literatura. REUMATOLOGIA CLINICA 2020; 16:430. [PMID: 30139689 DOI: 10.1016/j.reuma.2018.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/13/2018] [Accepted: 07/19/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Eva M Fonseca Aizpuru
- Servicio de Medicina Interna, Hospital Universitario de Cabueñes, Gijón, Asturias, España.
| | - Carlos Delgado Verges
- Servicio de Medicina Interna, Hospital Universitario de Cabueñes, Gijón, Asturias, España
| | | | - Luis Barcala Vázquez
- Servicio de Dermatología, Hospital Universitario de Cabueñes, Gijón, Asturias, España
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32
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Taha RY, Hasan S, Ibrahim F, Chantran Y, Sabah HE, Sivaraman S, Bozom IA, Sabbagh AA, Garderet L, Omri HE. Characterization of circulating myeloma tumor cells by next generation flowcytometry in scleromyxedema patient: a case report. Medicine (Baltimore) 2020; 99:e20726. [PMID: 32629647 PMCID: PMC7337479 DOI: 10.1097/md.0000000000020726] [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: 11/26/2022] Open
Abstract
INTRODUCTION Scleromyxedema (rare cutaneous mucinosis), is characterized by the formation of lichenoid papules and presence of Serum monoclonal IgG in most cases, or all; after repeated testing. PATIENT CONCERNS The patient is a 51-year-old male presented with thick, disfiguring elephant-like erythematous skin folds over the forehead, papular shiny eruptions over ears and trunk and waxy erythematous papules over arms and hands without dysphagia or respiratory or neurologic symptoms DIAGNOSIS: : Skin biopsy from right arm was consistent with scleromyxedema. Serum cryoglobulin was reported negative. Complete blood count and routine blood biochemistry were normal. Thyroid function tests were normal. Serum protein electrophoresis and immunofixation showed monoclonal band of 14.5 g/L typed as IgG lambda. INTERVENTIONS Our patient was refractory to lenalidomide however improved clinically on immunoglobulins infusions on monthly basis without change in the MGUS level. OUTCOMES NGF analysis revealed approximately 0.25% Lambda monotypic plasma cells in the bone marrow expressing CD38, CD138, and CD27 with aberrant expression of CD56 and were negative for CD45, CD19, CD117, and CD81. We also detected 0.002% circulating plasma cells (PCs) in peripheral blood. CONCLUSION The immunophenotype of circulating tumor cells (CTCs) remain close to the malignant PCs phenotype in the BM. Hence, we report NGF approach as a novel diagnostic tool for highly sensitive MRD detection in plasma cell dyscrasias including scleromyxedema.
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Affiliation(s)
- Ruba Y. Taha
- Hamad Medical Corporation, Hematology and Medical Oncology Department
| | - Saba Hasan
- Hamad Medical Corporation, Hematology and Medical Oncology Department
| | - Firyal Ibrahim
- Hamad Medical Corporations, department and Laboratory Medicine and Pathology, Doha, Qatar
| | | | - Hesham El Sabah
- Hamad Medical Corporation, Hematology and Medical Oncology Department
| | - Siveen Sivaraman
- Hamad Medical Corporations, Interim Translational research Institute iTRI, Doha, Qatar
| | - Issam Al Bozom
- Hamad Medical Corporations, department and Laboratory Medicine and Pathology, Doha, Qatar
| | - Ahmad Al Sabbagh
- Hamad Medical Corporations, department and Laboratory Medicine and Pathology, Doha, Qatar
| | - Laurent Garderet
- Maladies du sang CHU de l’AP-HP Hôpital St-Antoine 184 rue du fg St-Antoine 75571 Paris, France
| | - Halima El Omri
- Hamad Medical Corporation, Hematology and Medical Oncology Department
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Abstract
BACKGROUND AND OBJECTIVES Treatment of severe dermatological autoimmune diseases and toxic epidermal necrolysis (TEN) with high-dose intravenous immunoglobulin (IVIg) is a well-established procedure in dermatology. As treatment with IVIg is usually considered for rare clinical entities or severe cases, the use of immunoglobulin is not generally based on data from randomized controlled trials usually required for evidence-based medicine. Since the indications for the use of IVIg are rare, it is unlikely that such studies will be available in the foreseeable future. Because first-line use is limited by the high costs of IVIg, the first clinical guidelines on the use of IVIg in dermatological conditions were established in 2008 and renewed in 2011. METHODS The European guidelines presented here were prepared by a panel of experts nominated by the European Dermatology Forum (EDF) and European Academy of Dermatology and Venereology (EADV). The guidelines were developed to update the indications for treatment currently considered effective and to summarize the evidence for the use of IVIg in dermatological autoimmune diseases and TEN. RESULTS AND CONCLUSION The current guidelines represent consensual expert opinions and definitions on the use of IVIg reflecting current published evidence and are intended to serve as a decision-making tool for the use of IVIg in dermatological diseases.
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Magira EE, Malouchou A, Karathanasi V, Mavropoulou N, Siempos II, Vourlakou C, Sykaras A, Anastasiadis G. Acute Encephalitic Syndrome Induced by Scleromyxedema. Am J Med Sci 2020; 360:192-195. [PMID: 32540147 DOI: 10.1016/j.amjms.2020.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/20/2020] [Accepted: 05/14/2020] [Indexed: 10/24/2022]
Abstract
Dermato-neuro syndrome is a potentially fatal neurological complication of scleromyxedema consisting of fever, seizures, and coma. This is an overlooked scleromyxedema case of a 62-year-old female patient from 2-years ago. She was admitted to our ICU because of high fever, colloid speech, muscle ache, and nausea. Molecular methods in the cerebrospinal fluid for neurotropic viruses ruled out acute infectious encephalitis. Her thyroid hormones were within normal values while the serum protein electrophoresis confirmed the monoclonal gammopathy of immunoglobulin G lambda (IgG(λ)), known for the last 2 years. The subsequent bone-marrow biopsy excluded the development of multiple myeloma. The patient fulfilled fundamental diagnostic criteria of scleromyxedema (monoclonal gammopathy, normal thyroid function and the appearance of marked sclerosis and induration of the skin papules on the face, neck, extremities, and skin creases) presenting as dermato-neuro syndrome, which was histologically confirmed. She demonstrated a remarkable improvement after intravenous immunoglobulin treatment during the first 24 hours. Mimics of non-infectious acute encephalitis should include the clinical diagnosis of scleromyxedema, especially when patients present in the emergency department with acute fever, coma, and skin lesions of diffuse sclerodermoid and papular type.
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Affiliation(s)
- Eleni E Magira
- First Department of Critical Care, Evangelismos Hospital, National and Kapodistrian University of Athens, School of Medicine, University of Athens, Athens, Greece.
| | - Aikaterini Malouchou
- Dermatology Department, General Hospital of Athens, "Evangelismos", Athens, Greece
| | - Vasiliki Karathanasi
- Dermatology Department, General Hospital of Athens, "Evangelismos", Athens, Greece
| | - Niki Mavropoulou
- Dermatology Department, General Hospital of Athens, "Evangelismos", Athens, Greece
| | - Ilias I Siempos
- First Department of Critical Care, Evangelismos Hospital, National and Kapodistrian University of Athens, School of Medicine, University of Athens, Athens, Greece
| | - Christina Vourlakou
- Department of Pathology, General Hospital of Athens "Evangelismos", Athens, Greece
| | - Alexandros Sykaras
- Department of Pathology, General Hospital of Athens "Evangelismos", Athens, Greece
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Mecoli CA, Talbot CC, Fava A, Cheadle C, Boin F, Wigley FM, Hummers LK. Clinical and Molecular Phenotyping in Scleromyxedema Pretreatment and Posttreatment With Intravenous Immunoglobulin. Arthritis Care Res (Hoboken) 2020; 72:761-767. [PMID: 31008568 DOI: 10.1002/acr.23908] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 04/16/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Scleromyxedema (SMX) is a rare systemic sclerosis mimic that often responds to intravenous immunoglobulin (IVIG) therapy, yet the resulting clinical and biochemical changes have not been well characterized. To better understand the pathogenesis of the disease and the efficacy of IVIG, we sought to explore whether IVIG would introduce a measurable biologic effect corresponding with clinical improvement. METHODS Fifteen patients with SMX were recruited for the study. Clinical information and peripheral blood mononuclear cells for flow cytometry were obtained immediately before and again 1-2 weeks after patients received IVIG therapy. Ten patients also underwent skin biopsies for gene expression analysis both before and after IVIG therapy. Clinical data included measures of skin involvement (modification of the modified Rodnan skin thickness score [MMRSS] and percentage of body surface area) and several patient-reported outcome measures assessing patients' skin. RESULTS Posttreatment, the average MMRSS score decreased from mean ± SD 13.6 ± 2.6 to 10.3 ± 1.9; P = 0.003. There were also significant improvements in skin flexibility (mean ± SD 5.4 ± 0.8 to 3.2 ± 0.7; P = 0.003) and softening (mean ± SD 4.9 ± 0.9 to 2.6 ± 0.6; P = 0.022). Baseline levels of Tc17 cells (CD8+CCR6+CXCR3+CCR4-) correlated with the extent of skin involvement as measured by MMRSS pretreatment (r = 0.69, P = 0.012) and decreased after IVIG therapy (mean ± SD 3.4% ± 3.2% to 1.3% ± 1.7%; P = 0.008). Posttreatment analysis of RNA in skin tissue revealed a decrease in gene expression of transforming growth factor β (TGFβ) cytokines as well as several interferon-inducible proteins. CONCLUSION This open-label study further supports the evidence that patients with SMX respond both objectively and subjectively to IVIG therapy. Biologic studies suggest a role for T lymphocytes in the pathogenesis of the disease and reveal the potential significance of TGFβ and interferon pathways.
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Affiliation(s)
| | | | - Andrea Fava
- Johns Hopkins University, Baltimore, Maryland
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36
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Haber R, Bachour J, El Gemayel M. Scleromyxedema treatment: a systematic review and update. Int J Dermatol 2020; 59:1191-1201. [PMID: 32358980 DOI: 10.1111/ijd.14888] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 10/16/2019] [Accepted: 03/26/2020] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Scleromyxedema is a chronic disease with high morbidity and mortality and no definitive therapeutic guidelines. OBJECTIVE To review all available data on the efficacy and the safety of the available treatments of scleromyxedema and suggest a possible therapeutic approach. EVIDENCE REVIEW We performed a systematic literature review in Pubmed/Medline, Embase, and Cochrane collaboration databases, searching for all articles since 1990 on the treatments of scleromyxedema, with no limits on participant age, gender, or nationality. FINDINGS Ninety-seven studies were included in this systematic review, of which one prospective, two retrospective, 70 case reports/case series, and 24 letters/correspondence/clinical image. Intravenous immunoglobulin (IVIG) was the most used first-line therapy based on its efficacy and its generally well-tolerated nature; most patients require continued treatment to remain in remission. Thalidomide and systemic glucocorticoids were mostly considered as second-line therapies and were given alone or in association with IVIG. Patients with severe or refractory disease were treated with autologous bone marrow transplantation, melphalan, or bortezomib with dexamethasone. CONCLUSIONS AND RELEVANCE Consideration of patient comorbidities, disease distribution, clinician experience, and treatment accessibility is mandatory in every therapeutic approach of scleromyxedema.
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Affiliation(s)
- Roger Haber
- Department of Dermatology, Saint George Hospital University Medical Center, Beirut, Lebanon - Faculty of Medicine, Balamand University, Beirut, Lebanon
| | - Julien Bachour
- Department of Dermatology, Saint George Hospital University Medical Center, Beirut, Lebanon - Faculty of Medicine, Balamand University, Beirut, Lebanon
| | - Maria El Gemayel
- Department of Gastroenterology, Hotel Dieu de France University Hospital, Beirut, Lebanon - Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
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37
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Kim S, Park TH, Lee SM, Kim YH, Cho MK, Whang KU, Kim HS. Scleromyxedema with multiple systemic involvement: Successful treatment with intravenous immunoglobulin. Dermatol Ther 2020; 33:e13378. [PMID: 32250023 DOI: 10.1111/dth.13378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 11/29/2022]
Abstract
Scleromyxedema is a rare connective tissue disorder characterized by a generalized lichenoid eruption and sclerodermoid induration with histologic features of dermal mucin deposition. A 44-year-old man presented with a 3-year history of generalized progressive skin thickening and sclerosis. He had diffuse skin-colored to erythematous firm papules coalescing into indurated plaques over his whole body. He had been diagnosed with scleromyxedema from a skin biopsy with monoclonal gammopathy of undetermined significance (MGUS) at another tertiary hospital 3 years earlier. He had been treated with systemic corticosteroids and methotrexate, but his systemic symptoms (dyspnea, dysphagia, skin swelling, and induration) had worsened over the past year, so he visited our clinic seeking further evaluation and management. The patient received high-dose intravenous immunoglobulin (IVIG) therapy once a month in combination with systemic corticosteroids. After three courses of IVIG, his cutaneous symptoms and dyspnea had improved dramatically. Herein we report a case of scleromyxedema with systemic involvement with significant improvement following IVIG therapy.
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Affiliation(s)
- Sooyoung Kim
- Department of Dermatology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Tae Heum Park
- Department of Dermatology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Seung Min Lee
- Department of Dermatology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Yon Hee Kim
- Department of Pathology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Moon Kyun Cho
- Department of Dermatology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Kyu Uang Whang
- Department of Dermatology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Hyun-Sook Kim
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, South Korea
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38
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39
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Orteu CH, Ong VH, Denton CP. Scleroderma mimics - Clinical features and management. Best Pract Res Clin Rheumatol 2020; 34:101489. [PMID: 32147386 DOI: 10.1016/j.berh.2020.101489] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Systemic sclerosis is a severe immune-mediated rheumatic disease by virtue of its clinical impact and mortality. There are a number of other sclerosing skin diseases that should be considered in the differential diagnosis and these are important because they may require specialist investigation and management. In addition, long-term follow up of the different conditions should reflect the risk of associated complications and anticipated duration of therapy. This article reviews the clinical features of potential mimics of scleroderma (systemic sclerosis) including localised forms of scleroderma (morphoea) and other conditions that lead to skin thickening and connective tissue fibrosis or scarring.
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Affiliation(s)
- Catherine H Orteu
- Department of Dermatology, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, UK
| | - Voon H Ong
- Centre for Rheumatology, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, UK
| | - Christopher P Denton
- Centre for Rheumatology, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, UK.
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40
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Souchik AD, Dean AM, Tjarks BJ, Hossler EW, Strickler AG. Bumpy skin on the back, arms, and chest of a 4-year-old. Pediatr Dermatol 2020; 37:369-370. [PMID: 32196740 DOI: 10.1111/pde.14109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Adam D Souchik
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Audrey M Dean
- Department of Dermatology, Geisinger Medical Center, Danville, PA, USA
| | - Brian J Tjarks
- Department of Dermatopathology, Geisinger Medical Center, Danville, PA, USA
| | - Eric W Hossler
- Department of Dermatology, Geisinger Medical Center, Danville, PA, USA.,Department of Dermatopathology, Geisinger Medical Center, Danville, PA, USA
| | - Allen G Strickler
- Department of Dermatology, Geisinger Medical Center, Danville, PA, USA.,Department of Dermatopathology, Geisinger Medical Center, Danville, PA, USA
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41
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Kreidy M, Al-Hilli A, Yachoui R, Resnick J. Severe but reversible pulmonary hypertension in scleromyxedema and multiple myeloma: a case report. BMC Pulm Med 2020; 20:8. [PMID: 31918690 PMCID: PMC6953266 DOI: 10.1186/s12890-019-1020-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 12/06/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Scleromyxedema is a progressive, systemic connective tissue disorder characterized by fibro-mucous skin lesions and increased serum monoclonal immunoglobulin levels. Pulmonary involvement occurs in a subset of patients, though the overall prevalence of pulmonary lesions in scleromyxedema is unknown. Since pulmonary hypertension presumably occurs in these patients due to disease progression and development of additional conditions, treatment of the underlying plasma cell dyscrasia and connective tissue disorder may improve pulmonary hypertension symptoms. CASE PRESENTATION An elderly patient with scleromyxedema developed pulmonary hypertension refractory to vasodilator and diuretic therapy and subsequently multiple myeloma that responded to a combination therapy of bortezomib, cyclophosphamide, and dexamethasone treatment. CONCLUSIONS Treatment of the underlying disease(s) that contributed to pulmonary hypertension development with anti-neoplastic agents like bortezomib may improve cardiopulmonary symptoms secondary to reducing abnormal blood cell counts and paraprotein levels.
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Affiliation(s)
- Mazen Kreidy
- Department of Pulmonary and Critical Care Medicine, Marshfield Clinic, Marshfield, WI USA
- Present affiliation: Christiana Care Health System, PO Box 1668, Wilmington, DE 19899 USA
| | - Ali Al-Hilli
- Department of Internal Medicine, Marshfield Clinic, Marshfield, WI USA
| | - Ralph Yachoui
- Department of Rheumatology, Ronald Reagan UCLA Medical Center, Santa Monica, California, USA
| | - Jeffrey Resnick
- Department of Pathology, Marshfield Clinic, Marshfield, WI USA
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42
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Kalli F, Cioni M, Parodi A, Altosole T, Ferrera F, Barra G, De Palma R, Fenoglio D, Filaci G, Rongioletti F. Increased frequency of interleukin-4 and reduced frequency of interferon-γ and IL-17-producing CD4+ and CD8+ cells in scleromyxedema. J Eur Acad Dermatol Venereol 2020; 34:1092-1097. [PMID: 31912592 DOI: 10.1111/jdv.16136] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 11/12/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Little is known about the pathogenesis of scleromyxedema, a life-threatening fibromucinosis disease with immunological dysregulation. OBJECTIVES To investigate on T-cell phenotype, function and cytokine biology in search of new insights supporting the immunopathogenesis of the disease. METHODS We analysed the frequency of circulating lymphocyte subsets, the T-cell maturation stage, the generation of antigen-specific T-cell lines and T-cell cytokine secretion. RESULTS The analysis of T-cell maturation stage and the TCR spectratyping findings revealed that scleromyxedema patients showed clear immunological signs of long-lasting immune system activation and stimulation leading to a skewed T-cell repertoire. Moreover, these analyses showed that both CD4+ and CD8+ T cells from scleromyxedema patients have a profound deficiency (even after stimulation) relatively to the production of IFN-γ and IL17 with respect to healthy donor control cells, while they are massively skewed towards IL4 secretion after stimulation. CONCLUSIONS Our data indicate that a chronic Th2-skewed T-cell response against an unknown target antigen leading to abnormally high IL4 secretion, a pro-fibrotic cytokine, is a main immunological hallmark of scleromyxedema patients. These results, never reported before, may have a translational therapeutic value due to the availability of anti-IL4 agents such as dupilumab.
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Affiliation(s)
- F Kalli
- Centre of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
| | - M Cioni
- Section of Dermatology, DISSAL, University of Genoa, Genoa, Italy.,Section of Pathology, Department of Surgical and Morphological Sciences, University of Genoa, Genoa, Italy
| | - A Parodi
- Centre of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
| | - T Altosole
- Centre of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
| | - F Ferrera
- Centre of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
| | - G Barra
- Department of Precision Medicine, Università della Campania "L. Vanvitelli", Napoli, Italy
| | - R De Palma
- Institute of Protein Biochemistry, CNR, Napoli, Italy.,Department of Internal Medicine, University of Genoa- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - D Fenoglio
- Centre of Excellence for Biomedical Research, University of Genoa, Genoa, Italy.,Department of Internal Medicine, University of Genoa- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - G Filaci
- Department of Internal Medicine and Centre of Excellence for Biomedical Research, University of Genoa, Genoa, Italy.,Bioterapy Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - F Rongioletti
- Section of Pathology, Department of Surgical and Morphological Sciences, University of Genoa, Genoa, Italy.,Department of Medical Science and Public Health, Unit of Dermatology, University of Cagliari, Cagliari, Italy
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Varjú C, Kumánovics G, Czirják L, Matucci-Cerinic M, Minier T. Sclerodermalike syndromes: Great imitators. Clin Dermatol 2019; 38:235-249. [PMID: 32513403 DOI: 10.1016/j.clindermatol.2019.10.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Sclerodermalike syndromes (SLSs) comprise diseases with mucin deposition (eg, scleromyxedema, scleredema), with eosinophilia (eg, eosinophilic fasciitis), metabolic or biochemical abnormalities (eg, nephrogenic systemic fibrosis), or endocrine disorders (eg, POEMS syndrome, or polyneuropathy, organomegaly, endocrinopathy, monoclonal lymphoproliferative disorder, and hypothyroidism). Chronic graft-versus-host disease may also show sclerodermalike skin changes. Inherited progeria syndromes with early aging (eg, Werner syndrome) and a heterogeneous group of hereditary disorders with either skin thickening (eg, stiff skin syndrome) or atrophy and tightening (eg, acrogeria) can also imitate classic systemic sclerosis (SSc). In addition, SLSs can be provoked by several drugs, chemicals, or even physical injury (eg, trauma, vibration stress, radiation). In SLSs, the distribution of skin involvement seems to be atypical compared with SSc. The acral skin involvement is usually missing, and lack of Raynaud phenomenon, scleroderma-specific antinuclear antibodies, the absence of scleroderma capillary pattern, and internal organ manifestations indicate the presence of an SLS. Skin involvement is sometimes nodular, and the underlying tissues can also be affected. For the differential diagnosis, a skin biopsy of the deeper layers including fascia and muscle is required. Histology does not always allow differentiation between SSc and SLSs; therefore, the diagnosis is often based on the distribution, quality of cutaneous involvement, and other accompanying clinical features.
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Affiliation(s)
- Cecília Varjú
- Department of Rheumatology and Immunology, University of Pécs Clinical Center, Pecs, Hungary
| | - Gábor Kumánovics
- Department of Rheumatology and Immunology, University of Pécs Clinical Center, Pecs, Hungary
| | - László Czirják
- Department of Rheumatology and Immunology, University of Pécs Clinical Center, Pecs, Hungary
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology, Florence, Italy
| | - Tünde Minier
- Department of Rheumatology and Immunology, University of Pécs Clinical Center, Pecs, Hungary.
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44
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Hohaus K, Moelleken M, Hadaschik E, Dissemond J. [Brownish papules, pachydermia, and sclerosis with massive pruritus]. Hautarzt 2019; 71:78-80. [PMID: 31628496 DOI: 10.1007/s00105-019-04493-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
| | | | | | - Joachim Dissemond
- Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Essen, Hufelandstr. 55, 45122, Essen, Deutschland.
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45
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Cárdenas-Gonzalez RE, Ruelas MEH, Candiani JO. Lichen myxedematosus: a rare group of cutaneous mucinosis. An Bras Dermatol 2019; 94:462-469. [PMID: 31644623 PMCID: PMC7007042 DOI: 10.1590/abd1806-4841.20198478] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 01/14/2019] [Indexed: 11/22/2022] Open
Abstract
Cutaneous mucinoses are a heterogeneous group of dermatoses in which excess deposition of mucin in the dermis gives the skin a waxy appearance, with papules and plaques that can vary from self-healing mucinosis to even disrupting the normal shape of a patient's face, conferring a leonine facies, or be part of life threatening diseases like scleromyxedema. This review will describe the most recent classification on lichen myxedematosus in the generalized (scleromyxedema) and the localized forms, as well as the different organ systems involved in scleromyxedema, diagnostic workup, current management, and prognosis.
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Affiliation(s)
- Ramiro Eugenio Cárdenas-Gonzalez
- Dermatology Service, Hospital Universitario, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Maira Elizabeth Herz Ruelas
- Dermatology Service, Hospital Universitario, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Jorge Ocampo Candiani
- Dermatology Service, Hospital Universitario, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
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Wetzel M, Owen CE, Callen JP. Paraneoplastic Syndromes for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2019. [DOI: 10.1007/s13671-019-00277-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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47
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Atzori L, Ferreli C, Rongioletti F. New insights on scleromyxedema. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 4:118-126. [PMID: 35382389 PMCID: PMC8922651 DOI: 10.1177/2397198318824929] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 12/24/2018] [Indexed: 10/14/2023]
Abstract
Scleromyxedema is a rare fibromucinous disorders, with several clinical and pathological overlaps with scleroderma and scleredema. Etiopathogenesis remains uncovered, and no explanation has been provided either for the origin of mucin deposition or for the paraprotein role. The disease does not show gender predilection and affects mainly middle-age adults. The course is unpredictable, and prognosis remains guarded for renal, cardiac, and neurologic complications, especially in the setting of dermato-neuro syndrome. A valuable recent progress is the consensus definition of diagnostic criteria and lines of treatment, which hold the promise to improve the early recognition and management of this rare condition worldwide. High-dose intravenous immunoglobulin has been suggested as the first-line treatment either alone or associated with systemic steroids and/or thalidomide. In very recalcitrant cases, adjunctive bortezomib and/or autologous stem cell transplant might be considered. Melphalan treatment was associated with very toxic side effects and actually is no longer recommended.
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Affiliation(s)
- Laura Atzori
- Dermatology Clinic, Department Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Caterina Ferreli
- Dermatology Clinic, Department Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Franco Rongioletti
- Dermatology Clinic, Department Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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Pawlitschek T, Hajar T, Fett N. Abrupt Onset of Dysphagia, Arthritis, Joint Contractures, and Sheets of Monomorphous Waxy Papules. JAMA Dermatol 2019; 155:737-738. [DOI: 10.1001/jamadermatol.2018.5627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Tamar Hajar
- Department of Dermatology, Oregon Health and Science University, Portland
| | - Nicole Fett
- Department of Dermatology, Oregon Health and Science University, Portland
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Myopathy and scleromyxedema. J Neurol 2019; 266:2051-2059. [DOI: 10.1007/s00415-019-09379-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 05/13/2019] [Accepted: 05/15/2019] [Indexed: 10/26/2022]
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50
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Shenoy A, Steixner J, Beltrani V, Gottlieb A. Discrete Papular Lichen Myxedematosus and Scleromyxedema with Hypothyroidism: A Report of Two Cases. Case Rep Dermatol 2019; 11:64-70. [PMID: 31011315 PMCID: PMC6465707 DOI: 10.1159/000498881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 02/08/2019] [Indexed: 11/19/2022] Open
Abstract
Scleromyxedema and lichen myxedematosus (LM) are rare disorders that fall along the spectrum of primary cutaneous mucinoses. Scleromyxedema is a systemic form that classically presents with generalized waxy papules, sclerodermoid eruption, and monoclonal gammopathy; LM is a localized form limited to the skin that classically presents with white, firm, waxy papules and lacks monoclonal gammopathy. According to diagnostic criteria established in 2001, the diagnosis of both conditions requires absence of thyroid disease. However, atypical cases that lack monoclonal gammopathy and that present with hypothyroidism have been reported, suggesting that these criteria may require revision. First, we report a case of a 58-year-old female with a history of Hashimoto thyroiditis and biopsy-proven scleromyxedema responsive to intravenous immunoglobulin therapy with delayed presentation of monoclonal gammopathy. Next, we report a case of a 54-year-old female with a history of hypothyroidism, Hodgkin's lymphoma in remission after radiation and chemotherapy, and concurrent rheumatoid arthritis, with biopsy-proven LM temporarily responsive to systemic steroids. Our cases demonstrate that patients with papular mucinoses can have a multitude of concurrent and prior rheumatologic and endocrine conditions, including thyroid disease, which should not preclude a diagnosis of scleromyxedema and LM.
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Affiliation(s)
- Adele Shenoy
- School of Medicine, New York Medical College, Valhalla, New York, USA
- *Adele Shenoy, School of Medicine, New York Medical College, 40 Sunshine Cottage Road, Valhalla, NY 10019 (USA), E-Mail
| | | | | | - Alice Gottlieb
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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