Cutaneous manifestations of paraproteinaemia. Part II

Pyoderma Gangrenosum and IgA Myeloma

Background:

Pyoderma gangrenosum (PG) is an uncommon condition that is associated with a systemic disease in 50% of patients. The condition may be associated with a monoclonal gammopathy, usually of the IgA type. It is rare for PG to be associated with multiple myeloma.

Observations:

We report the case of an 83-year-old man with PG associated with an IgA myeloma. The myeloma was discovered after the diagnosis of PG had been made. This is the 22nd case of multiple myeloma associated with PG, and only the 14th case of PG with an IgA myeloma.

Conclusions:

We should be aware of the potential association of multiple myeloma with PG, and consider doing a serum protein electrophoresis in the evaluation of patients with PG.

Case of multiple myeloma associated with extramedullary cutaneous plasmacytoma and pyoderma gangrenosum

A variety of cutaneous manifestations has been described in multiple myeloma including extramedullary cutaneous plasmacytomas, cutaneous amyloidosis, pyoderma gangrenosum, leukocytoclastic vasculitis, necrobiotic xanthogranuloma, scleromyxedema, Sweet's syndrome, subcorneal pustular dermatosis, scleredema, and plane xanthomas etc. An 89-year-old Korean man, who had been suffering from multiple myeloma 1 year previous, presented for evaluation of two nodules on the right side of the forehead, left side of the chest (7th rib area), and multiple ulcers with papulopustules on both the thigh and the left side of the chest (2nd rib area) during 15 days, which developed at the same time. A biopsy of a lesion which manifested as a cutaneous nodule on the right side of the forehead revealed dermal infiltration by well-differentiated plasma cells, similar to those found on a bone marrow biopsy, and a biopsy of the lesion manifested as a painful ulceration on the right thigh area showing dermal neutrophilic infiltration. Histologic findings were consistent with plasmacytoma and pyoderma gangrenosum, respectively. We present a case of multiple myeloma which developed extramedullary cutaneous plasmacytoma and pyoderma gangrenosum simultaneously, which is very rare. The patient was treated with a systemic steroid and conservative therapy.

Pyoderma gangrenosum successfully treated with cyclosporin A

The subjects of the study are a 48-year old male and a 50-year female patient with the idiopathic form of pyoderma gangrenosum. Both patients were treated with Cyclosporin A (Sandimmun) as monotherapy. Complete resolution was achieved after three months' treatment. No serious side-effects were observed.

Diffuse plane xanthomatosis and acquired palmoplantar keratoderma in association with myeloma

We report a patient with diffuse plane xanthomatosis, acquired palmoplantar keratoderma, and myeloma. Although diffuse plane xanthomatosis is a recognized manifestation of paraproteinaemia, keratoderma is not. However, successful treatment of the myeloma in our patient coincided with a dramatic improvement in the keratoderma, suggesting a genuine association between the two disorders.

Subcorneal pustular dermatosis and IgA multiple myeloma

A case of subcorneal pustular dermatosis associated with IgA multiple myeloma is described. The significance of the combination of the two diseases is not yet known, but the association is certainly more than coincidence.

Subcorneal pustular dermatosis and IgA paraproteinaemia: response to both etretinate and PUVA

A non-insulin dependent male diabetic is reported with subcorneal pustular dermatosis associated with intraepidermal IgA deposits and a benign IgA paraproteinaemia. Treatment with dapsone and etretinate was reasonably effective, but etretinate had to be discontinued due to the development of diffuse idiopathic skeletal hyperostosis. His subcorneal pustular dermatosis subsequently flared and was troublesome for 2 years until he was commenced on PUVA, with excellent response.

Myeloma associated scleromyxedema with extensive involvement of small bowel

The details of a patient with disseminated scleromyxedema related to multiple myeloma are presented. Investigation demonstrated extensive accumulation of mucopolysaccharides in the skin, bone marrow and the small bowel submucosa. The latter finding is a most unusual manifestation of scleromyxedema and appeared to correlate with the patient's symptoms on presentation.

Pyoderma gangrenosum: a review

Pyoderma gangrenosum is a poorly understood disease characterized by exacerbations and remissions of morphologically unique skin ulcers. It frequently is thought to be the cutaneous manifestation of an underlying systemic disease. In this review of pyoderma gangrenosum, the characteristics of the disease are described and a differential diagnosis is formulated. Associations with systemic diseases are made through a review of the literature. The pathophysiology of pyoderma gangrenosum and probable causes are considered, and special consideration is given to the immunologic mechanisms that may be operative in the disease. Finally the currently available therapeutic alternatives are reviewed.

Myeloma, paraproteinemias, and the skin

This review focuses on those systemic diseases or syndromes associated with monoclonal plasma cell disorders that may present with important cutaneous manifestations. Amyloidosis, POEMS syndrome, cutaneous plasmacytoma, xanthomas, benign hypergammaglobulinemic purpura of Waldenström, and scleromyxedema are emphasized.

Subcorneal pustular dermatosis (Sneddon-Wilkinson disease) after a diagnostic echogram. Report of two cases

We reported two cases of subcorneal pustular dermatosis (Sneddon-Wilkinson disease) which developed several hours after performance of an echography. To the best of our knowledge, there are as yet no reports in the literature relating performance of echography with the appearance of this rare disease. The possible explanation of the relation between the dermatologic disorder and the performance of echography is discussed.

Subcorneal pustular dermatosis and monoclonal IgA

A patient with subcorneal pustular dermatosis was found to have a circulating monoclonal IgA kappa immunoglobulin. Direct immunofluorescence studies revealed IgA kappa deposits in the subcorneal zone of the epidermis. Circulating IgA kappa reacting with the subcorneal zone of normal human epidermis was demonstrated by indirect immunofluoresence. It is speculated that IgA deposition might be implicated in the pathogenesis of subcorneal pustular dermatosis.

The lipid composition and localization of free and esterified cholesterol in different types of xanthomas

The lipid composition of 17 xanthomatous lesions from 16 patients with different types of hyperlipoproteinaemia was analyzed. The relative amounts of free cholesterol, cholesterolesters, and phospholipids in xanthomas obtained from patients who subsequently showed regression of their remaining type of xanthomas were different in comparison with xanthomas which did not show regression. One tendinous xanthoma contained more than 50% free cholesterol and resembled in lipid composition the gruel plaques found in atherosclerotic lesions. The relative amounts of free cholesterol, cholesterolesters, and phospholipids in regressing xanthomas were similar to those of fatty streaks found in arteries of children between the ages of 5-10 yr. Histochemical studies using an enzymatic method demonstrated that free and esterified cholesterol were located in focal areas of xanthomatous tissue. It is concluded that the physical state of lipids in xanthomatous lesions can vary remarkably and plays an important role with regard to the possibility of regression.