Multiple myeloma presenting with an acute bacterial infection

Disparities in Outcomes of Hospitalizations Due to Multiple Myeloma: A Nationwide Comparison

Background With the advent of novel treatments, there is a declining trend in the multiple myeloma (MM) mortality rate with an increasing hospitalization rate. However, there is limited population-based data on trends and outcomes of hospitalizations due to MM in the United States (US). Methods We analyzed the publicly available Nationwide Inpatient Sample (NIS) from 2007 to 2017 to identify MM hospitalizations. Results Hospitalizations for MM increased from 17,100 (8.71%) in 2007 to 19,490 (9.92%) in 2017. The in-hospital mortality rate declined from 8.4% in 2007 to 4.9% in 2017 (P <0.001) and discharge to facilities decreased from 20.4% in 2007 to 17.4% in 2017 (P <0.001). The odds of in-hospital mortality were higher with increasing age (odds ratio (OR): 1.46; 95% confidence interval (CI): 1.38 -1.54; P <0.0001), pneumonia (OR: 4.18; 95% CI: 3.63 - 4.81, P <0.0001), septicemia (OR: 2.50; 95% CI: 2.22 - 2.82; P <0.0001), renal failure (OR: 1.48; 95% CI: 1.34 -1.64; P <0.0001), uninsured/self-pay insurance status (OR: 2.69; 95% CI: 2.18 - 3.3; P <0.0001), rural hospital (OR: 2.26; 95% CI: 1.88 -2.72; P<0.0001), and urban-non-teaching hospitals (OR: 1.38; 95% CI: 1.23 - 1.56; P <0.0001). Also, increasing age (OR: 1.14; 95% CI: 1.11-1.18, P <0.0001), Black race (OR: 1.12; 95% CI: 1.02-1.23, P <0.0001), and multiple comorbidities were associated with higher disability. Conclusion Hospitalizations for MM continued to increase, whereas in-hospital mortality continued to decrease. Advanced age, sepsis, pneumonia, and renal failure were associated with higher odds of mortality in MM patients.

BACTERIAL MENINGITIS IN PATIENTS WITH MULTIPLE MYELOMA: A PROSPECTIVE NATIONWIDE COHORT STUDY AND REVIEW OF THE LITERATURE

OBJECTIVE

To study the clinical features of bacterial meningitis in myeloma patients.

METHODS

We analyzed myeloma patients included in a nationwide cohort of patients >16 years old with community-acquired bacterial meningitis in the Netherlands between 2006 and 2018. Subsequently, we reviewed the literature for articles reporting myeloma patients with bacterial meningitis.

RESULTS

A total of 27 of 2306 (1.6%) episodes of bacterial meningitis occurred in myeloma patients. Six of 27 (22%) patients received stem cell transplantation. CSF showed a median leukocyte count of 172/µL and 12 (46%) of 26 patients had a CSF leukocyte count <100/µL. Streptococcus pneumoniae was the causative pathogen in 25 (93%) patients. Fourteen (52%) patients had unfavorable outcome of whom 10 (37%) died. Ninety-one myeloma patients with bacterial meningitis were described in the literature. The most common pathogen in these patients was S. pneumoniae (35 of 48; 73%) and four (20%) of 20 cases died.

CONCLUSION

Bacterial meningitis in patients with multiple myeloma is a severe disease with high rates of unfavorable outcome. Patients often present with a low CSF leukocyte count compared to bacterial meningitis in patients without multiple myeloma. Physicians should have a low threshold to perform a lumbar puncture in myeloma patients and start antibiotic treatment pending CSF chemistry and culture results.

Bacterial infections exacerbate myeloma bone disease

Multiple myeloma is characterized by osteolytic lesions caused by reduced bone formation and activated bone resorption. An important feature of myeloma is a failure of bone healing after successful treatment. In this work, clinical studies indicated a highly positive correlation between bone marrow bacteria abundance and bone lesion numbers of myeloma patients in complete remission. Coculture experiments demonstrated that marrow Escherichia coli (E. coli) promotes osteoclast differentiation and inhibits osteoblast differentiation. Mechanism studies showed that E. coli lipopolysaccharides (LPS) activated NF-κB p65 signaling and reduced phosphorylated smad1/5/9 binding ability with RUNX2 promoter, leading to decreased RUNX2 expression in osteoblast progenitors. Additionally, LPS enhanced phosphorylated NF-κB p65 binding ability with NFATc1 promoter, leading to increased NFATc1 expression in osteoclast progenitors. In vivo studies revealed E. coli contributes to osteolytic bone lesion, and elimination of E. coli infection assists healing of bone lesion in mouse model of myeloma in complete remission. These findings establish a heretofore unrecognized effect for E. coli in the genesis of myeloma bone disease and suggest a new treatment strategy.

More than Meets the Eye: Bacteremic Pneumococcal Pneumonia as the Initial Presentation of Multiple Myeloma

Patient: Male, 60-year-old

Final Diagnosis: Streptococcus pneumoniae bacteremia • multiple myeloma

Symptoms: Chills • cough • fever

Medication: —

Clinical Procedure: Bone marrow biopsy • CT scan • serology

Specialty: Hematology • Infectious Diseases • General and Internal Medicine

Case Studies and Literature Review of Pneumococcal Septic Arthritis in Adults

We saw an increase in this condition related to emergence of Streptococcus pneumoniae serotype 23B.

We conducted a retrospective study on all cases of pneumococcal septic arthritis (SA) in patients >18 years of age reported to the Picardie Regional Pneumococcal Network in France during 2005–2016. Among 1,062 cases of invasive pneumococcal disease, we observed 16 (1.5%) SA cases. Although SA is uncommon in adult patients, the prevalence of pneumococcal SA in the Picardie region increased from 0.69% during 2005–2010 to 2.47% during 2011–2016 after introduction of the pneumococcal 13-valent conjugate vaccine. We highlight the emergence of SA cases caused by the 23B serotype, which is not covered in the vaccine.

Infections in patients with multiple myeloma treated with conventional chemotherapy: a single-center, 10-year experience in Pakistan

Introduction

Multiple myeloma (MM) is a common hematologic malignancy with variable degrees of immunodeficiency. Disease- and treatment-related compromise of the immune system predisposes patients to infections, which are a major cause of morbidity and mortality.

Objective

We aimed to establish the incidence and main characteristics of infections in MM patients treated at our center over a 10-year period.

Method and results

Of the 412 patients retrospectively analyzed, 154 (37.4%) were documented to have at least one episode of infection and were included in this study. A total of 244 infectious episodes were documented. The most common site of infection was the lung, followed by the genitourinary system. The most common infections were bacterial, followed by viral. Escherichia coli were the most common organism. In 160 (65.5%) episodes, the organism was not isolated. Thalidomide with dexamethasone was the most common treatment regimen, followed by melphalan with dexamethasone. Infection was the main cause of death in 26 (6.3%) out of all 412 patients.

Conclusion

Infections are a notable cause of morbidity and mortality in the clinical course of MM patients. By considering patient and disease characteristics, a risk-adapted selection of the MM treatment should be employed, with special attention toward patient age and disease-associated organ dysfunction. Patient education, access to healthcare and physician vigilance are also essential. Vaccination and antimicrobial prophylaxis may be considered prior to or during therapy.

Streptococcus pneumoniae Osteomyelitis in a 25-Year-Old Man as the Initial Presentation of Multiple Myeloma: A Case Report

CASE

We report the case of a 25-year-old man with femoral Streptococcus pneumoniae pyomyositis as well as hypercalcemia, mild anemia, and elevated inflammatory markers; he subsequently was diagnosed with immunoglobulin G (IgG) kappa multiple myeloma.

CONCLUSION

Multiple myeloma most commonly affects patients who are >60 years of age, and causes clinical symptoms from anemia, lytic bone lesions, hypercalcemia, and renal failure. These findings and a monoclonal protein spike serve as initial diagnostic and treatment criteria. Multiple myeloma is associated with susceptibility to bacterial infections, especially encapsulated organisms; however, this is rarely the initial presentation. Additionally, it is unusual for myeloma to be diagnosed in a young person (<40 years of age).

Immunogenicity and persistence of the 13-valent Pneumococcal Conjugate Vaccine (PCV13) in patients with untreated Smoldering Multiple Myeloma (SMM): A pilot study

Smoldering multiple myeloma (SMM) is an asymptomatic clonal plasma cell disorder that frequently progress to multiple myeloma (MM), a disease at high risk of pneumococcal infections. Moreover, if the polysaccharide vaccine is poorly immunogenic in MM, the 13-valent conjugated vaccine has never been tested in clonal plasma cell disorders. We evaluated its immunogenicity for 7 serotypes in 20 patients ≥ 50 years of age with smoldering multiple myeloma (SMM) pre and post routine-vaccination with PCV13.

Concentrations of IgG specific for 7 serotypes were measured at baseline, 1, 6, and 12 months after vaccination by standardized ELISA and an Opsonophagocytic Assay (OPA). The primary endpoint was the proportion of patients responding to at least 5 of the 7 serotypes by ELISA at one month.

At 1 month post vaccination, 12 patients (60%) were responders by ELISA, among whom 8 were also responders by OPA. At 6 months, 6 (30% of total) of the 12 responders had persistent immunity, and only 2 (10% of total) at 12 months. These results suggested a partial response in this population and a rapid decrease in antibody levels in the first months of vaccination.

Although one injection of the 13-valent pneumococcal conjugate vaccine is immunogenic in some patients with SMM, the response is transient. Repeated injections are likely to be needed for effective and sustained protection.

Management of patients with malignancies and secondary immunodeficiencies treated with immunoglobulins in clinical practice: Long-term data of the SIGNS study

OBJECTIVE

We aimed to describe the current management and outcomes of patients with secondary immunodeficiencies (SID) on intravenous (IV) or subcutaneous (SC) immunoglobulins (IG) as maintenance therapy to prevent infections.

METHODS

Non-interventional, prospective study (average follow-up 20.5 months).

RESULTS

Of the 307 SID patients (mean age 63.7±14.4 years, 52% males, in 31% IG newly initiated), 95.4% received IV IG (mean dosing interval 4.6 weeks, average dose 199 mg/kg per 4 weeks) and 4.6% were treated with SC IG (2.6 weeks, 343 mg/kg per 4 weeks). Median IG through level at first documentation was 5.8 g/L and did not differ between IV and SC treatment or between underlying malignancies. In 24.1% of patients, treatment was interrupted temporarily, over a mean of 11.6±6.3 months. In patients with newly initiated IG treatment the 82% overall infection rate prior to treatment dropped to 21% at 1 year.

CONCLUSIONS

Under clinical practice conditions, IG replacement therapy in SID patients was feasible, diminished infection rates and improved quality of life. Average IG doses were relatively low. Tolerability of IV IG treatment was excellent.

Risk factors and characteristics of blood stream infections in patients with newly diagnosed multiple myeloma

BACKGROUND

Patients with multiple myeloma are generally immune-compromised either due to pronounced depression in primary antibody responses or because of anti-myeloma therapy. Infection is a major risk factor for early deaths among these patients. The impact of blood stream infections (BSI) on newly diagnosed myeloma patients has been less studied. We aimed to study the incidence and risk factors of BSI within 3 months after diagnosis of multiple myeloma in a tertiary referral center.

METHODS

Between November 2002 and December 2008, consecutive patients with multiple myeloma in Taipei Veterans General Hospital were retrospectively enrolled. Characteristics of patients with or without BSI were collected. Possible factors associated with development of BSI were analyzed by Cox regression.

RESULTS

There were a total of 222 patients. The incidence of BSI within 3 months after diagnosis is 11.7%. The patients with BSI had poorer survival outcomes than those without (mortality rate: 50% vs. 20.9%, p < 0.001). Moreover, advanced International Staging System stage (stage III vs. I/II: odds ratio [OR] 2.69, p = 0.049) and poor Eastern Cooperative Oncology Group (ECOG) performance status (ECOG > 2 vs. ≤ 2: OR 3.58, p = 0.005) were the independent risk factors of BSI, whereas immunoglobulin deficiency and low absolute lymphocyte count were not associated with risk of BSI development.

CONCLUSIONS

Our study highlights the characteristic of myeloma patients with BSI and the importance of disease and host factors on risk of BSI. Myeloma patients with risks of BSI should be properly managed to reduce early mortality.

Acute Mono-Arthritis of the Knee: A Case Report of Infection with Parvimonas Micra and Concomitant Pseudogout

Parvimonas micra is a rare pathogen for septic arthritis and is known for its subacute onset. We report a case of acute arthritis of the knee caused by P. micra and pseudogout. Initially, calcium pyrophosphate crystals were found in the knee, which were successfully treated with a steroid injection. Only anaerobic cultures became positive. A 16S rRNA PCR-analysis was necessary to identify P. micra as causative agent, a method which is never described before in similar cases. The infection was treated with clindamycin for 6 weeks. This is the third case report of a septic arthritis caused by P. micra and the second which also reports concomitant pseudogout.

Assessment and monitoring of patients receiving chemotherapy for multiple myeloma: strategies to improve outcomes

Improved understanding as to the biology of multiple myeloma (MM) and the bone marrow microenvironment has led to the development of new drugs to treat MM. This explosion of new and highly effective drugs has led to dramatic advances in the management of MM and underscores the need for supportive care. Impressive and deep response rates to chemotherapy, monoclonal antibodies, and small molecule drugs provide hope of a cure or prolonged remission for the majority of individuals. For most patients, long-term, continuous therapy is often required to suppress the malignant plasma cell clone, thus requiring clinicians to become more astute in assessment, monitoring, and intervention of side effects as well as monitoring response to therapy. Appropriate diagnosis and monitoring strategies are essential to ensure that patients receive the appropriate chemotherapy and supportive therapy at relapse, and that side effects are appropriately managed to allow for continued therapy and adherence to the regimen. Multiple drugs with complex regimens are currently available with varying side effect profiles. Knowledge of the drugs used to treat MM and the common adverse events will allow for preventative strategies to mitigate adverse events and prompt intervention. The purpose of this paper is to review updates in the diagnosis and management of MM, and to provide strategies for assessment and monitoring of patients receiving chemotherapy for MM.

IL-10 mediates plasmacytosis-associated immunodeficiency by inhibiting complement-mediated neutrophil migration

BACKGROUND

Plasmacytosis (ie, an expansion of plasma cell populations to much greater than the homeostatic level) occurs in the context of various immune disorders and plasma cell neoplasia. This condition is often associated with immunodeficiency that causes increased susceptibility to severe infections. Yet a causative link between plasmacytosis and immunodeficiency has not been established.

OBJECTIVE

Because recent studies have identified plasma cells as a relevant source of the immunosuppressive cytokine IL-10, we sought to investigate the role of IL-10 during conditions of polyclonal and neoplastic plasmacytosis for the regulation of immunity and its effect on inflammation and immunodeficiency.

METHODS

We used flow cytometry, IL-10 reporter (Vert-X) and B cell-specific IL-10 knockout mice, migration assays, and antibody-mediated IL-10 receptor blockade to study plasmacytosis-associated IL-10 expression and its effect on inflammation and Streptococcus pneumoniae infection in mice. ELISA was used to quantify IL-10 levels in patients with myeloma.

RESULTS

IL-10 production was a common feature of normal and neoplastic plasma cells in mice, and IL-10 levels increased with myeloma progression in patients. IL-10 directly inhibited neutrophil migration toward the anaphylatoxin C5a and suppressed neutrophil-dependent inflammation in a murine model of autoimmune disease. MOPC.315.BM murine myeloma leads to an increased incidence of bacterial infection in the airways, which was reversed after IL-10 receptor blockade.

CONCLUSION

We provide evidence that plasmacytosis-associated overexpression of IL-10 inhibits neutrophil migration and neutrophil-mediated inflammation but also promotes immunodeficiency.

Multiple myeloma complicated with pseudomonas endocarditis

Patients diagnosed with multiple myeloma are more susceptible to infections which are the major causes of morbidity and mortality associated to this disease. The main infectious agents involved are Gram-positive bacteria. However, after chemotherapy an increase in the incidence of Gram-negative strains is observed. These bacteria are also responsible for most cases of urinary tract infections. Here is reported a rare case in a 73-year-old man with multiple myeloma who developed endocarditis due to pseudomonas.

Common community-acquired infections and subsequent risk of multiple myeloma: a population-based study

The role of bacteria and viruses as aetiological agents in the pathogenesis of cancer has been well established for several sites, including a number of haematological malignancies. Less clear is the impact of such exposures on the subsequent development of multiple myeloma (MM). Using the population-based U.S. Surveillance Epidemiology and End Results-Medicare dataset, 15,318 elderly MM and 200,000 controls were identified to investigate the impact of 14 common community-acquired infections and risk of MM. Odds ratios (ORs) and associated 95% confidence intervals (CIs) were adjusted for sex, age and calendar year of selection. The 13-month period prior to diagnosis/selection was excluded. Risk of MM was increased by 5-39% following Medicare claims for eight of the investigated infections. Positive associations were observed for several infections including bronchitis (adjusted OR 1.14, 95% CI 1.09-1.18), sinusitis (OR 1.15, 95% CI 1.10-1.20) pneumonia (OR 1.27, 95% CI 1.21-1.33), herpes zoster (OR 1.39, 95% CI 1.29-1.49) and cystitis (OR 1.09, 95% CI 1.05-1.14). Each of these infections remained significantly elevated following the exclusion of more than 6 years of claims data. Exposure to infectious antigens may therefore play a role in the development of MM. Alternatively, the observed associations may be a manifestation of an underlying immune disturbance present several years prior to MM diagnosis and thereby part of the natural history of disease progression.

Brain abscess caused by Nocardia cyriacigeorgica in two patients with multiple myeloma: novel agents, new spectrum of infections

OBJECTIVE AND IMPORTANCE

Introduction of high-dose chemotherapy and the novel agents including bortezomib, Lenalidomide, and Thalidomide has provided a significant progress in the treatment of multiple myeloma (MM) with an increase in median overall survival up to 6-8 years. However, the advances in myeloma treatment comes at a price with new spectrum of treatment-related infectious complications which should be taken into consideration while treating these patients.

CLINICAL PRESENTATION

We report here two patients with Ig G λ MM presenting with intracerebral mass lesions in the abscence of constitutional symptoms that would suggest an infectious etiology. Both patients had severe hypogammaglobulinemia and lymphopenia, which was attributed to treatment regimens including bortezomib. Intervention The surgical intervention-revealed abscess in both cases caused by Nocardia cyriacigeorgica, a relatively new pathogen which rarely causes infections in humans and also an unexpected pathogen in myeloma patients.

CONCLUSION

Although every aspect of immune system is known to be affected in MM, humoral immune deficiency is the hallmark of the inherent immune defect in this disease. Introduction of the novel agents, bortezomib in particular seems to have changed the characteristics of the immune dysfunction and the spectrum of the opportunistic infections by causing qualitative and quantitative changes in cellular immunity. The new spectrum of infectious agents might not be limited to hepatitis B and herpes zoster. Monitoring lymphopenia and administration of prophylactic antimicrobial agents accordingly could be considered in patients treated with bortezomib.