Multiple myeloma complicated by Evans syndrome

IgA plasma cell myeloma presenting as cold agglutinin-induced haemolytic transfusion reaction

Cold agglutinins produced in the setting of B cell neoplasms, such as lymphoplasmacytic lymphoma and plasma cell myeloma, can mediate autoimmune haemolytic anemia. Transfusion of these patients can exacerbate cold agglutinin-mediated haemolysis. Moreover, the workup for these reactions represents a diagnostic challenge due in part to false negative direct antiglobulin tests (DATs). Here, we report an anaemic patient who after a red blood cell (RBC) transfusion performed without blood warming, experienced a DAT-negative haemolytic transfusion reaction, and was later diagnosed with IgA-multiple myeloma, which showed an uncommon granular pattern by CD138 immunohistochemistry. Extensive workup excluded other diagnostic possibilities, including the presence of Donath-Landsteiner antibodies and cryoglobulins. Successful treatment with CyBorD (cyclophosphamide, bortezomib and dexamethasone) achieved complete remission, and additional RBC transfusions using warmers were completed uneventfully.

A Case of Multiple Myeloma Presenting with Gastrointestinal Bleeding and Evans Syndrome

Autoimmune events are rare in multiple myeloma (MM). Herein, we report a rare case of a patient presenting with recurrent gastrointestinal (GI) bleeding of unknown origin, also having pancytopenia eventually diagnosed as MM with Evans syndrome. This is an uncommon disorder presenting as autoimmune hemolytic anemia (AIHA) with immune thrombocytopenia purpura (ITP). A 56-year-old African American male presenting with recurrent GI bleeds and pancytopenia of unknown origin developed acute colonic diverticulitis on recurrent admissions, and sigmoid colectomy with primary anastomosis was performed. Flow cytometry with serum protein electrophoresis eventually revealed IgG MM with elevated Kappa/Lambda ratio. Bone marrow biopsy revealed 80% to 90% Kappa clonal plasma cells confirming MM. Direct antiglobulin test (DAT) was positive with pancytopenia. The patient initially showed a good response to chemotherapy with thrombocytopenia improving with intravenous (I/V) dexamethasone. DAT done after completion of initial chemotherapy was negative. However, his disease relapsed after three months with pancytopenia and DAT becoming positive again. The patient was restarted on chemotherapy for debulking, which resulted in a negative DAT again after two months, but pancytopenia did not improve. The patient eventually passed away due to subarachnoid hemorrhage. We highlight only this fourth reported case because of its unique presentation. In elderly patients with unknown cause of GI bleeding with pancytopenia, blood dyscrasias, especially MM, should be considered. Autoimmune workup if positive might warrant the use of steroids for pancytopenia, which can improve thrombocytopenia in MM with Evans syndrome but not anemia.

A Rare Case of Multiple Myeloma Presenting as Evan's Syndrome

Multiple myeloma is defined as the neoplastic proliferation of plasma cells resulting in a monoclonal gammopathy. The classic presentation of a patient is someone who presents with bone pain, osteopenia, or new onset fractures. We present a case of multiple myeloma presenting as Evan’s syndrome (ES). Evan’s syndrome is autoimmune hemolytic anaemia with autoimmune thrombocytopenia. A 44-year-old female was referred from her primary physician to the hospital as laboratory testing revealed haemoglobin of 5 gm/dL. The patient reported a two-month history of fatigue and a sixty-pound weight loss. Laboratory results demonstrated autoimmune hemolytic anaemia, C3 positivity, elevated immunoglobulin (Ig)G, elevated lactate dehydrogenase (LDH), low haptoglobin, elevated reticulocyte count, elevated RDW-CV (red blood cell distribution width-corpuscular volume), positive direct Coombs test, thrombocytopenia, and proteinuria, all of which led to an underlying ES. The patient was started on intravenous steroids followed by oral steroids. A flow cytometry, serum protein electrophoresis, and cytogenetics were obtained. A bone marrow biopsy revealed multiple myeloma and she was started on Bortezomib treatment. We present the fifth reported case of Evan’s syndrome and multiple myeloma.

Concomitant multiple myeloma, gastric adenocarcinoma and Evan's syndrome in a patient presenting with anaemia

An association between multiple myeloma (MM) and solid tumours has been previously described.¹ Furthermore, autoimmune disorders can precede plasma cell dyscrasias, and the pathogenesis of MM maybe linked to chronic immune stimulation. ² We describe a case of concomitant MM and gastric adenocarcinoma preceded by Evan's syndrome. A previously healthy woman presented to the emergency room with symptomatic anaemia. Her initial workup was compatible with autoimmune haemolytic anaemia and monoclonal gammopathy of undetermined significance. On progression of the anaemia and development of thrombocytopenia, she was diagnosed with Evan's syndrome. Two months later, she presented with severe back pain and her MRI revealed L4-5 vertebral collapse. The clinical picture was compatible with MM. Occult blood was repeatedly positive in stools, and she underwent oesophagogastroduodenoscopy and was found to have gastric adenocarcinoma. The patient refused surgical resection of the adenocarcinoma and refused active treatment for MM.

Multiple myeloma associated with an Evan's syndrome

Auto-immun events are rare in multiple myeloma (MM). Here, we report one MM case complicated by Evans syndrome (Autoimmun hemolytic anemia (AIHA) associated with thrombocytopenia). A 52-year-old man was admitted in nephrology department with severe anemia, renal insufficiency and hypergamma globulinemia. Laboratory exams showed acute hemolysis due to an IgG warm autoantibody. Serum electrophoresis revealed the presence of a monoclonal IgG protein and urinary M protein was 2g/day. A whole body CT-Scan showed osteolytic lesions of vertebral body of C5, D4, L3, L4 and the left iliac wing. The diagnosis of multiple myeloma and Evan's syndrome was made, we underwent chemotherapy by BTD (bortezomib-thalidomide-dexamethasone) and continuous corticosteroid therapy but unfortunately the patient died secondary of a Lactic acidosis. The relationship between MM and hemolysis remain unclear.

Autoimmune manifestations in patients with multiple myeloma and monoclonal gammopathy of undetermined significance

Background

Multiple myeloma (MM) and its precursor, monoclonal gammopathy of undetermined significance (MGUS), have been linked with several autoimmune conditions in the medical literature. Yet, significance of these associations is not well understood.

Methods

Herein, we provide a comprehensive literature review on autoimmune disorders identified in patients with MM and MGUS. Most relevant papers were identified via searching the PubMed/Medline and EMBASE databases for articles published from inception until May 1, 2016.

Findings

Scientific literature on autoimmune conditions in patients with MM and MGUS consists of several case series and a multitude of case reports. Our analysis suggests an increased prevalence of autoimmune conditions in patients with MM and monoclonal gammopathy of undetermined significance (MGUS), including various autoimmune hematologic and rheumatologic conditions among other entities. Conversely, persons with various autoimmune conditions tend to have a higher prevalence of MGUS and MM than the general population.

Conclusions

Future research is required to explore further the link between MGUS/MM and autoimmune disorders. Inflammation in the setting of autoimmunity may serve as a trigger for MGUS and MM. In addition, a common genetic susceptibility for developing both an autoimmune disease and MM/MGUS might also exist. Autoimmune hematologic and rheumatologic diseases may pose important clinical problems for the MM patients. Therefore, a catalogue of these problems is important so that physicians are able to consider, identify and address them promptly.

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A comprehensive review linking MM and MGUS with autoimmune disorders

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There is increased prevalence of autoimmune conditions in patients with MM and MGUS

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Most autoimmune disorders precede the development of plasma cell dyscrasias

Prevalence of autoimmune hemolytic anemia in multiple myeloma: A prospective study

AIM

Autoimmune hemolytic anemia (AIHA) is frequently associated with B-cell lymphoproliferative disorders, and patients rarely develop overt clinical manifestations of AIHA. AIHA is rare in patients with multiple myeloma (MM). We conducted a prospective study to detect the presence of AIHA in MM patients and its impact on clinical presentation and outcome of the disease.

METHODS

Sixty-six patients were diagnosed to have MM. Seventeen of these patients who had severe anemia (hemoglobin < 6 g/dL) requiring frequent blood transfusions with or without features of hemolysis were screened for AIHA by performing direct and indirect antiglobulin (Coombs') test.

RESULTS

Seven (10.6%) of these 17 patients were found to be complicated with AIHA and carried autoantibodies in their sera. Five patients had de novo MM and two had relapsed MM. Six patients (85.7%) had stage IIIA disease and one (14.3%) had stage IIIB disease. The IgG subclass of the antibody binding to red cell membrane was compared with that of M-protein and these findings showed full correlation in all the seven patients. All of these patients were positive for subtypes of IgG and one patient had simultaneous positivity for IgA and IgG2, with presence of cold antibodies in the serum. Patients with primary disease showed remission of AIHA with therapy, whereas both the patients with relapsed disease showed no response to treatment and remained positive for antiglobulin test.

CONCLUSION

AIHA should be suspected in MM patients with severe anemia requiring frequent blood transfusions.

Multiple myeloma presenting with autoimmune hemolytic anemia

Autoimmune hemolysis is rare in multiple myeloma. We describe a rare case of multiple myeloma who presented with autoimmune hemolytic anemia at initial presentation.

Clinical features and outcomes of autoimmune hemolytic anemia: a retrospective analysis of 32 cases

Background

There has been no report on the clinical features or natural history of autoimmune hemolytic anemia (AIHA) in the Korean adult population. This study retrospectively analyzed the clinical characteristics and long-term outcomes of AIHA in the Korean adults.

Methods

Patients newly diagnosed with AIHA between January 1994 and December 2010 at Chungnam National University Hospital were enrolled. Patient characteristics at diagnosis, response to treatment, and the natural course of the disease were documented.

Results

Thirty-two patients (31 females and 1 male) with a median age of 48 years (range, 17-86) were enrolled. Of these, 21.9% were initially diagnosed with secondary AIHA. Thirteen patients (40.6%) were initially diagnosed with Evans' syndrome. Of the 29 patients who were placed on therapy, 27 (93.1%) showed a partial response or better. Nevertheless, 1 year after initiating treatment, 80% of the patients were still treatment-dependent. During follow-up (median length 14 months; range, 0.5-238), 14 of 25 patients (56.0%) who were initially diagnosed with primary warm antibody AIHA were found to have systemic lupus erythematosus (SLE). Median time to conversion to SLE was 8.0 months (95% CI, 4.3-11.7), and the probabilities of conversion at 12 and 24 months were 63% and 91%, respectively. Younger age (<60 years) and a positive fluorescent anti-nuclear antibody test were associated with a higher probability of SLE conversion (P=0.01 and P<0.001, respectively).

Conclusion

Primary AIHA is rare. Regular, vigilant testing for SLE is required in patients initially diagnosed with AIHA.