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Nguyen NV, Konstantinou EK, Sherif N, Soifer M, Patronas M, Allen J, Bellur SS, Kodati S. Bilateral Exudative Retinal Detachments and Panuveitis in a Patient with Multiple Myeloma. Ocul Immunol Inflamm 2024; 32:1448-1453. [PMID: 37290057 PMCID: PMC10703998 DOI: 10.1080/09273948.2023.2217914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/18/2023] [Accepted: 05/21/2023] [Indexed: 06/10/2023]
Abstract
PURPOSE To report a case of bilateral exudative retinal detachments and panuveitis in a patient with multiple myeloma (MM). CASE REPORT A 54-year-old patient with non-proliferative diabetic retinopathy was referred with blurred vision and scotomas in both eyes (OU). Three months prior to the onset of ocular symptoms, he was diagnosed with systemic MM and was receiving chemotherapy. Clinical examination revealed best-corrected visual acuities of 20/80 OU, rare anterior chamber cell, 2+ vitreous cell, diffuse intraretinal hemorrhages, and exudative retinal detachments (RD). Optical coherence tomography of the macula showed central subretinal fluid with cystic intraretinal fluid OU. The findings were consistent with panuveitis and exudative RD in the setting of MM. He reported symptomatic improvement after plasmapheresis and oral prednisone initiation. CONCLUSION Extensive, bilateral exudative RD and panuveitis are rare but potentially sight-threatening findings in patients with MM.
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Affiliation(s)
- Nam V. Nguyen
- National Eye Institute, National Institutes of Health, Bethesda, Maryland
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Noha Sherif
- National Eye Institute, National Institutes of Health, Bethesda, Maryland
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Matias Soifer
- National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - Marena Patronas
- Department of Ophthalmology, George Washington University, Washington, District of Columbia
| | | | - Sunil S. Bellur
- National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - Shilpa Kodati
- National Eye Institute, National Institutes of Health, Bethesda, Maryland
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Zhu K, Zhou Y, Lei B, Li J, Shen Z, Tang N, Weng X, Chang Q, Xu G, Wang M. Multimodal Imaging of Bilateral Retinal Pigment Epithelial Immunoglobulin Light Chain Deposition in Patients with Systemic Immunoglobulin Light Chain Deposition. Ophthalmol Retina 2024:S2468-6530(24)00334-8. [PMID: 39033925 DOI: 10.1016/j.oret.2024.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 07/02/2024] [Accepted: 07/15/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVE To describe multimodal imaging of peculiar bilateral globular subretinal deposits and acquired serous retinal detachment in patients with systemic immunoglobulin light chain deposition. DESIGN A retrospective observational case series. PARTICIPANTS We examined 6 eyes in 3 patients (1 with multiple myeloma, 1 with membranous nephropathy, and 1 with immunoglobulin A nephropathy) at the Eye and ENT Hospital of Fudan University. The patients presented with peculiar globular subretinal deposits along the retinal pigment epithelium (RPE)‒Bruch's membrane complex and acquired serous retinal detachment. METHODS Fundus appearance was documented with multimodal imaging, which included fundus photography, fundus autofluorescence, spectral domain OCT, swept-source OCT (SS-OCT), en face OCT, and SS-OCT angiography. Additional evaluations included serum protein electrophoreses, positron emission tomography computed tomography, and renal and bone biopsies to assess the primary diseases. MAIN OUTCOME MEASURES Multimodal imaging, course, and prognosis of bilateral RPE immunoglobulin light chain deposition in patients with systemic immunoglobulin light chain deposition. RESULTS Bilateral, multiple, speckled, or patchy RPE changes in the posterior fundus that corresponded to striking multifocal hyperautofluorescence on fundus autofluorescence and lumpy, globular hyperreflective deposits along the RPE‒Bruch's membrane complex were identified as characteristic features of bilateral RPE light chain deposition. These features may be accompanied by dense light chain deposits in the choriocapillaris and choroid vessels, diffuse choroidal thickening, and "angiographically silent" serous retinal detachment in patients with systemic immunoglobulin light chain deposition. CONCLUSIONS We have documented the characteristic features, clinical course, and prognosis of bilateral RPE immunoglobulin light chain deposition in patients with systemic immunoglobulin light chain deposition. Appropriate evaluations, including serum protein electrophoresis and hematologic consultation, are recommended to manage patients with this fundus abnormality. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
- Ke Zhu
- Eye Institute and Department of Ophthalmology, Eye and Ear Nose Throat Hospital of Fudan University, Shanghai, China; Shanghai Key Laboratory of Visual Impairment and Restoration, Fudan University, Shanghai, China; Key Laboratory of Myopia, National Healthcare Commission, Key Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
| | - Yao Zhou
- Eye Institute and Department of Ophthalmology, Eye and Ear Nose Throat Hospital of Fudan University, Shanghai, China; Shanghai Key Laboratory of Visual Impairment and Restoration, Fudan University, Shanghai, China; Key Laboratory of Myopia, National Healthcare Commission, Key Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
| | - Boya Lei
- Eye Institute and Department of Ophthalmology, Eye and Ear Nose Throat Hospital of Fudan University, Shanghai, China; Shanghai Key Laboratory of Visual Impairment and Restoration, Fudan University, Shanghai, China; Key Laboratory of Myopia, National Healthcare Commission, Key Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
| | - Jing Li
- Department of Hematology, Zhongshan Hospital of Fudan University, Shanghai, China
| | - Ziyan Shen
- Department of Nephrology, Zhongshan Hospital of Fudan University, Shanghai Medical Center of Kidney Disease, Shanghai, China
| | - Nuo Tang
- Eye Institute and Department of Ophthalmology, Eye and Ear Nose Throat Hospital of Fudan University, Shanghai, China; Shanghai Key Laboratory of Visual Impairment and Restoration, Fudan University, Shanghai, China; Key Laboratory of Myopia, National Healthcare Commission, Key Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
| | - Xinyi Weng
- Eye Institute and Department of Ophthalmology, Eye and Ear Nose Throat Hospital of Fudan University, Shanghai, China; Shanghai Key Laboratory of Visual Impairment and Restoration, Fudan University, Shanghai, China; Key Laboratory of Myopia, National Healthcare Commission, Key Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
| | - Qing Chang
- Eye Institute and Department of Ophthalmology, Eye and Ear Nose Throat Hospital of Fudan University, Shanghai, China; Shanghai Key Laboratory of Visual Impairment and Restoration, Fudan University, Shanghai, China; Key Laboratory of Myopia, National Healthcare Commission, Key Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
| | - Gezhi Xu
- Eye Institute and Department of Ophthalmology, Eye and Ear Nose Throat Hospital of Fudan University, Shanghai, China; Shanghai Key Laboratory of Visual Impairment and Restoration, Fudan University, Shanghai, China; Key Laboratory of Myopia, National Healthcare Commission, Key Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China
| | - Min Wang
- Eye Institute and Department of Ophthalmology, Eye and Ear Nose Throat Hospital of Fudan University, Shanghai, China; Shanghai Key Laboratory of Visual Impairment and Restoration, Fudan University, Shanghai, China; Key Laboratory of Myopia, National Healthcare Commission, Key Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China.
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Finn MJ, Sharma A, Guenena M, Jiang Y, Savant SV, Ramsey DJ. Bilateral sequential ischemic retinopathy and optic neuropathy in IgG1 heavy chain deposition disease. Eur J Ophthalmol 2024:11206721241257553. [PMID: 38815990 DOI: 10.1177/11206721241257553] [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: 06/01/2024]
Abstract
PURPOSE To report a case of progressive ischemic retinopathy and optic neuropathy in a patient with heavy chain deposition disease (HCDD), a rare form of monoclonal immunoglobulin deposition disease (MIDD). OBSERVATIONS Our case describes a 74-year-old woman diagnosed with IgG1 lambda HCDD. After treatment with daratumumab and intravenous IVIG therapy, the patient developed worsening ischemic retinopathy and optic neuropathy, neovascular glaucoma, and bilateral sequential vitreous hemorrhages, necessitating surgical intervention. We present multimodal imaging from the onset of ischemic retinopathy to end-stage maculopathy illustrated by optical coherence tomography (OCT) angiography. Despite discontinuing treatment with daratumumab and providing maximal ocular interventions to control the complications of neovascular disease, the patient's condition progressed, resulting in profound vision loss. CONCLUSIONS AND IMPORTANCE Our case illustrates the potential for HCDD to cause end-organ disease, including ischemic retinopathy and optic neuropathy, possibly worsened by the patient's underlying cardiovascular risk factor status and medications. Daratumumab, a humanized IgG1 kappa monoclonal antibody that binds to CD38 used to treat specific blood cancers, has been reported to cause disturbances in retinal blood flow, including retinal artery and vein occlusions. It remains to be determined whether careful patient selection or dose adjustments and timing of HCDD treatments could protect vision by reducing the risk of these rare yet severe ocular complications.
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Affiliation(s)
- Matthew J Finn
- Lahey Department of Surgery, Division of Ophthalmology, UMass Chan Medical School, University of Massachusetts, Burlington, MA, USA
- Department of Ophthalmology, Tufts University School of Medicine, Boston, MA, USA
| | - Arjun Sharma
- Lahey Department of Surgery, Division of Ophthalmology, UMass Chan Medical School, University of Massachusetts, Burlington, MA, USA
- Department of Ophthalmology, Tufts University School of Medicine, Boston, MA, USA
| | | | - Ying Jiang
- Lahey Department of Surgery, Division of Ophthalmology, UMass Chan Medical School, University of Massachusetts, Burlington, MA, USA
- Department of Ophthalmology, Tufts University School of Medicine, Boston, MA, USA
| | - Shravan V Savant
- Lahey Department of Surgery, Division of Ophthalmology, UMass Chan Medical School, University of Massachusetts, Burlington, MA, USA
- Department of Ophthalmology, Tufts University School of Medicine, Boston, MA, USA
| | - David J Ramsey
- Lahey Department of Surgery, Division of Ophthalmology, UMass Chan Medical School, University of Massachusetts, Burlington, MA, USA
- Department of Ophthalmology, Tufts University School of Medicine, Boston, MA, USA
- Spindel Eye Associates, Derry, NH, USA
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Dou R, Chu Y, Han Q, Zhang W, Bi X. Giant retinal pigment epithelium tears with membranous nephropathy: a case report and literature review. BMC Ophthalmol 2024; 24:177. [PMID: 38632537 PMCID: PMC11025203 DOI: 10.1186/s12886-024-03426-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Kidney and eye diseases may be closely linked. Tears of the retinal pigment epithelium (RPE) have been reported to be related to kidney diseases, such as IgA nephropathy and light-chain deposition disease. However, pigment epithelium tears associated with membranous nephropathy have not been reported or systematically analysed. CASE PRESENTATION A 68-year-old man presented with decreased right eye visual acuity. Optical coherence tomography (OCT) revealed cystic macular edema, localized serous detachment of the retina and loss of the outer retinal structure in the right eye and retinal pigment epithelium detachment (PED) combined with serous detachment of the retina in the left eye. Fundus fluorescein angiography (FFA) and indocyanine green angiography (ICGA) revealed giant RPE tears in the right eye and exudative age-related macular degeneration in the left eye. The patient also suffered from severe membranous nephropathy-autoimmune glomerulonephritis. Renal biopsy immunofluorescence revealed a roughly granular pattern, with immunoglobulin G (IgA), immunoglobulin G (IgG), IgM, complement C3(Components 3), λ light chain and κ light chain subepithelial staining. CONCLUSIONS It is hypothesized that severe membranous nephropathy caused immune complex deposition on the surface of Bruch membrane, resulting in weakened adhesion between the RPE and Bruch membrane and impaired RPE pump function, combined with age-related macular degeneration, leading to giant RPE tears in the right eye. Close attention should be given to the ocular condition of patients with membranous nephropathy to facilitate timely treatment and avoid serious consequences.
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Affiliation(s)
- Rui Dou
- Tianjin Key Lab of Ophthalmology and Visual Science, Tianjin Eye Hospital, Tianjin, 300070, China
| | - Yanhua Chu
- Tianjin Key Lab of Ophthalmology and Visual Science, Tianjin Eye Hospital, Tianjin, 300070, China.
| | - Quanhong Han
- Tianjin Key Lab of Ophthalmology and Visual Science, Tianjin Eye Hospital, Tianjin, 300070, China
| | - Wei Zhang
- Tianjin Key Lab of Ophthalmology and Visual Science, Tianjin Eye Hospital, Tianjin, 300070, China
| | - Xue Bi
- Tianjin Key Lab of Ophthalmology and Visual Science, Tianjin Eye Hospital, Tianjin, 300070, China
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Singh RB, Singhal S, Sinha S, Cho J, Nguyen AXL, Dhingra LS, Kaur S, Sharma V, Agarwal A. Ocular complications of plasma cell dyscrasias. Eur J Ophthalmol 2023; 33:1786-1800. [PMID: 36760117 PMCID: PMC10472748 DOI: 10.1177/11206721231155974] [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: 06/02/2022] [Accepted: 01/21/2023] [Indexed: 02/11/2023]
Abstract
Plasma cell dyscrasias are a wide range of severe monoclonal gammopathies caused by pre-malignant or malignant plasma cells that over-secrete an abnormal monoclonal antibody. These disorders are associated with various systemic findings, including ophthalmological disorders. A search of PubMed, EMBASE, Scopus and Cochrane databases was performed in March 2021 to examine evidence pertaining to ocular complications in patients diagnosed with plasma cell dyscrasias. This review outlines the ocular complications associated with smoldering multiple myeloma and monoclonal gammopathy of undetermined significance, plasmacytomas, multiple myeloma, Waldenström's macroglobulinemia, systemic amyloidosis, Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy and Skin changes (POEMS) syndrome, and cryoglobulinemia. Although, the pathological mechanisms are not completely elucidated yet, wide-ranging ocular presentations have been identified over the years, evolving both the anterior and posterior segments of the eye. Moreover, the presenting symptoms also help in early diagnosis in asymptomatic patients. Therefore, it is imperative for the treating ophthalmologist and oncologist to maintain a high clinical suspicion for identifying the ophthalmological signs and diagnosing the underlying disease, preventing its progression through efficacious treatment strategies.
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Affiliation(s)
- Rohan Bir Singh
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
- Department of Ophthalmology, Great Ormond Street Institute of Child Health, University College London, London, UK
- Discipline of Ophthalmology and Visual Sciences, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Sachi Singhal
- Department of Internal Medicine, Crozer-Chester Medical Center, Upland, PA, USA
| | - Shruti Sinha
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Junsang Cho
- Department of Ophthalmology, Vanderbilt Eye Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Lovedeep Singh Dhingra
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Snimarjot Kaur
- Department of Pediatrics, Yale-New Haven Hospital, New Haven, CT, USA
| | - Vasudha Sharma
- Department of Internal Medicine, Dayanand Medical College and Hospital, Ludhiana, India
| | - Aniruddha Agarwal
- Department of Ophthalmology, University of Maastricht, Maastricht, the Netherlands
- Department of Ophthalmology, The Eye Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
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Ogata N, Ueda K, Aoki S. Immunogammopathy Maculopathy Secondary to Waldenström's Macroglobulinemia Complicated With Diabetic Retinopathy: A Case Report and Literature Review. Cureus 2023; 15:e41622. [PMID: 37565119 PMCID: PMC10410483 DOI: 10.7759/cureus.41622] [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: 07/09/2023] [Indexed: 08/12/2023] Open
Abstract
In Waldenström's Macroglobulinemia (WM), increased immunoglobulin M causes various signs and symptoms. It sometimes presents with macular edema. A 65-year-old WM patient with a five-year history of diabetes mellitus was evaluated for ocular complications. Fundus examination and optical coherence tomography showed retinal changes consistent with non-proliferative diabetic retinopathy and foveal detachment with intraretinal cysts in the right eye, suggesting diabetic macular edema. However, on fluorescein angiography, there was no leakage over the area of foveal detachment, which led to the diagnosis of immunogammopathy maculopathy secondary to WM for macular edema and foveal detachment. The patient's ocular manifestation remained unchanged through a follow-up period of 11 months without therapeutic interventions. Immunogammopathy maculopathy, a rare ocular manifestation of monoclonal gammopathy, demands differentiation from other causes of macular edema in WM patients. The present case highlights the importance of fluorescein angiography, or silent macula, in diabetic patients to distinguish immunogammopathy maculopathy from diabetic macular edema.
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Affiliation(s)
- Nayumi Ogata
- Ophthalmology, Tokyo Teishin Hospital, Tokyo, JPN
| | - Kohei Ueda
- Ophthalmology, University of Tokyo, Tokyo, JPN
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Lejoyeux R, Benillouche J, Ong J, Errera MH, Rossi EA, Singh SR, Dansingani KK, da Silva S, Sinha D, Sahel JA, Freund KB, Sadda SR, Lutty GA, Chhablani J. Choriocapillaris: Fundamentals and advancements. Prog Retin Eye Res 2021; 87:100997. [PMID: 34293477 DOI: 10.1016/j.preteyeres.2021.100997] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/02/2021] [Accepted: 07/13/2021] [Indexed: 12/19/2022]
Abstract
The choriocapillaris is the innermost structure of the choroid that directly nourishes the retinal pigment epithelium and photoreceptors. This article provides an overview of its hemovasculogenesis development to achieve its final architecture as a lobular vasculature, and also summarizes the current histological and molecular knowledge about choriocapillaris and its dysfunction. After describing the existing state-of-the-art tools to image the choriocapillaris, we report the findings in the choriocapillaris encountered in the most frequent retinochoroidal diseases including vascular diseases, inflammatory diseases, myopia, pachychoroid disease spectrum disorders, and glaucoma. The final section focuses on the development of imaging technology to optimize visualization of the choriocapillaris as well as current treatments of retinochoroidal disorders that specifically target the choriocapillaris. We conclude the article with pertinent unanswered questions and future directions in research for the choriocapillaris.
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Affiliation(s)
| | | | - Joshua Ong
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Marie-Hélène Errera
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Ethan A Rossi
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; Department of Bioengineering, University of Pittsburgh Swanson School of Engineering, Pittsburgh, PA 15213, USA
| | - Sumit R Singh
- Jacobs Retina Center, Shiley Eye Institute, University of California San Diego, San Diego, CA, USA
| | - Kunal K Dansingani
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Susana da Silva
- Department of Ophthalmology and Department of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Debasish Sinha
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; Department of Cell Biology and Center for Biologic Imaging, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - José-Alain Sahel
- Rothschild Foundation, 75019, Paris, France; Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; Sorbonne Université, INSERM, CNRS, Institut de la Vision, Paris, France; CHNO des Quinze-Vingts, INSERM-DGOS CIC 1423, Paris, France
| | - K Bailey Freund
- LuEsther T. Mertz Retinal Research Center, Manhattan Eye, Ear, and Throat Hospital, New York, NY, USA; Vitreous Retina Macula Consultants of New York, New York, NY, USA; Department of Ophthalmology, New York University of Medicine, New York, NY, USA; Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA
| | - SriniVas R Sadda
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, CA, 90033, USA; Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Gerard A Lutty
- Wilmer Ophthalmological Institute, Johns Hopkins Hospital, Baltimore, MD, 21287, USA
| | - Jay Chhablani
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
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Wisely CE, Zhang W, Grewal DS. Multiple Myeloma Presenting as Recalcitrant Macular Edema. JOURNAL OF VITREORETINAL DISEASES 2020; 4:248-252. [PMID: 37007440 PMCID: PMC9982255 DOI: 10.1177/2474126419880491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: This article presents an unusual case of ocular involvement of multiple myeloma masquerading as macular edema associated with diabetic retinopathy. Methods: A report of a single case. Results: The presence of concomitant type 2 diabetes and scattered retinal hemorrhages presented a diagnostic challenge. Large globular vitreous opacities and significant weight loss were suggestive of a neoplastic process. We demonstrate multimodal imaging findings that can be associated with plasma cell dyscrasias and also describe the purported mechanism by which plasma cell dyscrasias cause macular edema and exudative retinal detachments. Conclusion: Although multiple myeloma and related plasma cell dyscrasias are rare causes of ocular disease, they should be considered in the differential diagnosis of recalcitrant macular edema, and there should be a low threshold for systemic evaluation.
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Affiliation(s)
- C. Ellis Wisely
- Department of Ophthalmology, Duke University Health System, Durham, NC, USA
| | - Wenlan Zhang
- Department of Ophthalmology, Duke University Health System, Durham, NC, USA
| | - Dilraj S. Grewal
- Department of Ophthalmology, Duke University Health System, Durham, NC, USA
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Maculopathy in Patients with Monoclonal Gammopathy of Undetermined Significance. Ophthalmol Retina 2019; 4:300-309. [PMID: 31753810 DOI: 10.1016/j.oret.2019.09.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/25/2019] [Accepted: 09/30/2019] [Indexed: 11/21/2022]
Abstract
PURPOSE To describe clinical findings, laboratory values, and treatment response of patients with monoclonal gammopathy of undetermined significance (MGUS) demonstrating neurosensory macular detachment. DESIGN Retrospective case series. PARTICIPANTS Seven eyes of 4 patients (3 men and 1 woman; age range, 60-81 years) with neurosensory macular detachment, treatment-resistant submacular fluid, and vitelliform material. METHODS We retrospectively reviewed the medical and ocular histories, ocular examination findings, retinal imaging, ocular disease course, and laboratory findings in 4 patients with submacular fluid associated with MGUS. MAIN OUTCOME MEASURES Description of the macular findings and treatment courses of 4 patients diagnosed with MGUS maculopathy. RESULTS Seven eyes of 4 patients demonstrated neurosensory macular detachment with treatment-resistant submacular fluid and vitelliform material. No eyes demonstrated signs of significant hyperviscosity retinopathy. Fluorescein angiography showed no definite leakage in any involved eye. Laboratory evaluation revealed immunoglobulin G MGUS in all 4 patients. All 4 patients were resistant to treatments aimed at resolving the subretinal fluid, including some combination of anti-vascular endothelial growth factor injections, photodynamic therapy, topical dorzolamide, oral dosing of eplerenone or acetazolamide, or some combination thereof. In 3 patients, MGUS underwent malignant transformation 24 to 144 months after diagnosis, in 1 patient to lymphoplasmacytic lymphoma and in 2 patients to multiple myeloma. The fourth patient showed no evidence of malignancy 8 years after diagnosis. CONCLUSIONS Submacular fluid without fluorescein leakage and unresponsive to conventional treatment may suggest an underlying immunoproliferative disorder that we have termed monoclonal gammopathy of macular significance. Given the propensity for monoclonal gammopathy of macular significance to transform into malignant disease in our series, serum protein analysis should be considered in patients with neurosensory macular detachment not attributable to known causes.
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Dhrami-Gavazi E, Freund KB, Lee W, Cohen BZ, Seshan SV, Yannuzzi LA. OCULAR MANIFESTATIONS OF MONOCLONAL IMMUNOGLOBULIN LIGHT CHAIN DEPOSITION DISEASE. Retin Cases Brief Rep 2018; 11:310-315. [PMID: 27315323 DOI: 10.1097/icb.0000000000000351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
PURPOSE To demonstrate unusual retinal findings in a patient with progressive renal failure due to idiopathic monoclonal immunoglobulin light chain deposition disease, using multimodal imaging. METHODS Observational case report of a 43-year-old white man with renal failure due to light chain deposition disease. His course over 6 years was documented with multimodal imaging including fundus photography, fundus autofluorescence, fluorescein angiography, and spectral domain optical coherence tomography. Additional evaluations included ocular ultrasound, electroretinography, positron emission tomography, serum protein electrophoreses, skeletal surveys to detect osteolytic lesions, and renal, liver, and rectal biopsies in search of amyloid. RESULTS The patient's ocular course mirrored the severity of his renal dysfunction for which he required a renal transplant. Changes observed in the native kidney recurred in the transplant 2 years later, as evidenced by immunohistochemistry, revealing thick linear deposits of kappa chains, with no complement, overlying the glomerular basement membrane. The systemic workup was negative for amyloid but showed an overwhelming ratio of kappa to lambda light chains on serum protein electrophoreses and no clinical signs of plasma cell dyscrasias, all consistent with idiopathic light chain deposition disease. The patient presented with a generalized, bilateral "leopard-spot" fundus appearance on fundus autofluorescence, striking globular subretinal deposits on spectral domain optical coherence tomography, and subfoveal subretinal fluid without retinal pigment epithelium detachment or choroidal effusions. The subfoveal fluid did not respond to intravitreal injections of antiangiogenic agents or steroids but resolved after renal transplantation. A temporary posttransplant visual improvement was associated with lessening of the subretinal drusenoid deposits demonstrated by multimodal imaging. The terminal vision deterioration was associated with amorphous, vitelliform-like material deposition and atrophic changes. CONCLUSION This case may illustrate a resemblance in the renal glomerulus basement membrane and retinal pigment epithelium-Bruch membrane complex, because the authors observed deposits of excess monoclonal kappa chains manifesting as extracellular, proteinaceous aggregates on the basement membrane of the glomerulus, and striking, globular subretinal deposits that overlay a thickened retinal pigment epithelium-Bruch membrane complex. The ocular lesions' refractoriness to intravitreal treatments could be attributed to the fact that they represent proteinaceous aggregates similar to those documented in the glomeruli. This is the first report of generalized, large, subretinal drusenoid deposits and their course, as documented through multimodal imaging, paralleling the chronology of systemic changes in a patient with light chain deposition disease.
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Affiliation(s)
- Elona Dhrami-Gavazi
- *Vitreous Retina Macula Consultants of New York, New York, New York, The LuEsther T. Mertz Retinal Research Center, Manhattan Eye Ear and Throat Hospital, New York, New York; †Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University, College of Physicians and Surgeons, New York, New York; ‡Department of Ophthalmology, New York University School of Medicine, New York, New York; §Retina Associates of New York; and ¶Department of Pathology, Weill Cornell Medical College, New York, New York
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ATYPICAL MACULOPATHY IN A PATIENT WITH LIGHT CHAIN DEPOSITION DISEASE MIMICKING ADVANCED GEOGRAPHIC ATROPHY. Retin Cases Brief Rep 2016; 11:83-85. [PMID: 26934302 PMCID: PMC5214371 DOI: 10.1097/icb.0000000000000295] [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: 11/25/2022]
Abstract
PURPOSE To report a previously unreported presentation of advanced geographic atrophy of the macula mimicking nonneovascular (dry) age-related macular degeneration in a patient with light chain deposition disease. METHODS Ocular examination included dilated fundus examination, fundus autofluorescence, full-field electroretinography, and spectral domain optical coherence tomography. PATIENTS Single-patient case report. RESULTS Dilated fundus examination demonstrated diffuse loss of the retinal pigment epithelium in a geographic atrophy pattern in the macula and drusenlike deposits localized to the outer retina and retinal pigment epithelium. There were no signs of choroidal neovascularization or retinal pigment epithelium detachments. Fundus autofluorescence demonstrated wide areas of retinal pigment epithelium loss. Full-field electroretinography was normal. Spectral domain optical coherence tomography displayed atrophy of the outer retinal layers. DISCUSSION This is the first documented case of drusenlike deposits and maculopathy in a patient with light chain deposition disease that mimics advanced geographic atrophy that is typically observed in nonneovascular age-related macular degeneration. Physicians should be aware of the macular changes that can be associated with light chain deposition disease, and patients with light chain deposition disease should be regularly evaluated for associated macular disease.
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Xu LT, Courtney RJ, Ehlers JP. Bevacizumab therapy and multimodal ultrawide-field imaging in immunogammopathy maculopathy secondary to Waldenström's macroglobulinemia. Ophthalmic Surg Lasers Imaging Retina 2015; 46:262-5. [PMID: 25707055 DOI: 10.3928/23258160-20150213-06] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 09/05/2014] [Indexed: 12/18/2022]
Abstract
Waldenström's macroglobulinemia (WM) is associated with retinal findings of hyperviscosity, such as venous dilation, and findings of immunogammopathy maculopathy, such as serous macular detachment. This report describes a case of bilateral serous macular detachment with intraretinal schisis-like fluid in a patient with WM. Enhanced depth imaging optical coherence tomography revealed a thickened choroid with hyperreflective accumulations in the retinal pigment epithelium layer. Ultrawide-field fundus autofluorescence demonstrated a central area of hyperautofluorescence corresponding to the area of serous macular detachment. Ultrawide-field fluorescein angiography was characteristically silent. Intravitreal bevacizumab therapy resulted in significant reduction in intraretinal fluid but minimal change in subretinal fluid. Long-term follow-up demonstrated alterations in retinal architecture and improved serous detachments.
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ENHANCED DEPTH IMAGING SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY FEATURES OF LIGHT CHAIN DEPOSITION DISEASE. Retin Cases Brief Rep 2015; 9:281-5. [PMID: 26398301 DOI: 10.1097/icb.0000000000000189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe a previously unreported finding in the choroid of a patient with light chain deposition disease on enhanced depth imaging optical coherence tomography. METHODS Clinical examination, fundus photography, fundus autofluorescence, fluorescein angiography, indocyanine green angiography, and spectral domain enhanced depth imaging optical coherence tomography were performed in a patient with light chain deposition disease. RESULTS This 45-year-old white man presented with decreased vision in both eyes. Clinical examination and color fundus photography revealed multiple ill-defined deep yellow lesions in the macula and periphery with granular retinal pigment epithelium changes in the macula of both eyes. The yellow lesions displayed increased autofluorescence, hyperfluorescence on fluorescein angiography, and hypocyanescence on indocyanine green angiography. Spectral domain enhanced depth imaging optical coherence tomography demonstrated irregularities of the outer retina, choroidal thickening with dilated outer choroidal vessels, and near-confluent hyperreflectivity of the choriocapillaris. CONCLUSION Patients with light chain deposition disease may have characteristic findings on spectral domain enhanced depth imaging optical coherence tomography that corroborate previously reported histopathologic findings in light chain deposition disease. This rare disease should be considered in the differential diagnosis for infiltrative choroidopathies.
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Roybal CN, Sanfilippo CJ, Nazari H, Law JC, Bhaleeya S, Chui Ming GC, Rao NA, Kiss S, Agarwal A, Sadda S, Sarraf D. MULTIMODAL IMAGING OF THE RETINA AND CHOROID IN SYSTEMIC AMYLOIDOSIS. Retin Cases Brief Rep 2015; 9:339-346. [PMID: 26421891 DOI: 10.1097/icb.0000000000000215] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
PURPOSE To present the multimodal imaging findings of four patients with systemic amyloidosis, renal failure, and chorioretinopathy. METHODS Retrospective analysis of four patients presenting to four institutions with evidence of amyloid induced chorioretinopathy. Fundus photography, autofluorescence, and spectral domain optical coherence tomography findings were studied and are presented. RESULTS Four patients with biopsy-proven systemic amyloidosis demonstrated progressive chorioretinal degeneration with color fundus photography and autofluorescent imaging. With spectral domain optical coherence tomography analysis, amyloidosis-induced chorioretinopathy was characterized by a widened choriocapillaris band, choroidal infiltration, diffuse photoreceptor dysfunction, and thinning of the outer nuclear layer. CONCLUSION Multimodal imaging including spectral domain optical coherence tomography analysis in eyes of patients with systemic amyloidosis shows deposition in the choroid. The deposition may cause a secondary toxic and or barrier effect resulting in diffuse retinal pigment epithelium and photoreceptor dysfunction.
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Affiliation(s)
- C Nathaniel Roybal
- *Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics, Iowa City, Iowa; †Retinal Disorders and Ophthalmic Genetics Division, David Geffen School of Medicine, Stein Eye Institute, University of California, Los Angeles, California; ‡University of Southern California Eye Institute, Los Angeles, California; §Department of Ophthalmology, Vanderbilt Eye Institute, Nashville, Tennessee; ¶Medical Retina Service, Singapore National Eye Centre, Singapore; **Department of Ophthalmology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York; ††Doheny Eye Institute, Los Angeles, California; ‡‡Greater Los Angeles Veterans Affairs Healthcare Center, Los Angeles, California; and §§Department of Ophthalmology, University of South Florida, Tampa, Florida
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Mansour AM, Arevalo JF, Badal J, Moorthy RS, Shah GK, Zegarra H, Pulido JS, Charbaji A, Amselem L, Lavaque AJ, Casella A, Ahmad B, Paschall JG, Caimi A, Staurenghi G. Paraproteinemic maculopathy. Ophthalmology 2014; 121:1925-32. [PMID: 24950591 DOI: 10.1016/j.ophtha.2014.04.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 03/06/2014] [Accepted: 04/09/2014] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Paraproteinemia relates to monoclonal gammopathy-producing pathologic antibodies with serous macular detachment being an uncommon ocular manifestation. We ascertained the clinical course of maculopathy in paraproteinemia and investigated the effect of various therapeutic methods on the resolution of subretinal deposits. DESIGN Multicenter, retrospective, observational case series. PARTICIPANTS The records of patients with paraproteinemia with optical coherence tomography (OCT) documentation of serous macular detachment were reviewed. METHODS Data collection included coexisting morbidity, rheology data (immunoglobulin level, hematocrit, and blood viscosity), clinical examination results, and OCT findings. MAIN OUTCOME MEASURES Best-corrected visual acuity (BCVA), height and basal area of the serous macular detachment, and systemic versus local therapies. RESULTS A total of 33 cases were collected: 10 new and 23 previously reported in the literature. Diabetes was present in 7 patients, systemic hypertension in 9 patients, and anemia in 18. Mean initial immunoglobulin level was 6497 mg/dl, and mean serum viscosity was 5.5 centipoise (cP). Mean logarithm of the minimum angle of resolution initial vs. final BCVA was 0.55 (Snellen equivalent, 20/71) vs. 0.45 (20/56) in the right eye and 0.38 (20/48) vs. 0.50 (20/63) in the left eye. After mean follow-up of 7 months (range, 0-51 months). Systemic therapies included plasmapheresis (18), chemotherapy (30), blood transfusions (2), transplantation of progenitor hematopoietic cells (2), and oral rituximab (10). Immunoglobulin levels normalized in 8 patients and were unchanged in 1 after plasmapheresis, chemotherapy, or both. Ocular therapy in 8 patients included vitrectomy (1), laser photocoagulation (4), intravitreal bevacizumab (5), intravitreal triamcinolone (2), intravitreal dexamethasone implant (1), intravitreal rituximab (1), and sub-Tenon corticosteroid (1). The maculopathy resolved partially or completely in 17 patients and worsened or remained unchanged in 14 patients over median follow-up of 7 months. Maculopathy was unilateral in 9 cases and occurred at a lower initial immunoglobulin level in diabetics. There was a positive correlation between area of the detachment and serum viscosity. CONCLUSIONS Paraproteinemic maculopathy can be unilateral. Decreasing the blood immunoglobulin level is the primary goal of therapy for paraproteinemic maculopathy, and this can be achieved by a systemic route. Coexisting diabetes facilitates leakage of immunoglobulins at lower levels than in nondiabetics.
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Affiliation(s)
- Ahmad M Mansour
- Departments of Ophthalmology, American University of Beirut and Rafic Hariri University Hospital, Beirut, Lebanon.
| | - J Fernando Arevalo
- Retina Departments, The King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia, and Wilmer Eye Institute, The Johns Hopkins University, Baltimore, Maryland
| | - Josep Badal
- Department of Ophthalmology, Hospital Moises Broggi Sant Joan Despi, Barcelona, Spain
| | - Ramana S Moorthy
- Associated Vitreoretinal and Uveitis Consultants, Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | - Jose S Pulido
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | - Abdulrazzak Charbaji
- Department of Statistics and Research Methodology, Lebanese American University and Lebanese University, Beirut, Lebanon
| | - Luis Amselem
- Department of Ophthalmology, Hospital Moises Broggi Sant Joan Despi, Barcelona, Spain
| | | | - Antonio Casella
- Department of Ophthalmology, Universidade Estadual de Londrina, Parana, Brazil
| | | | - Joshua G Paschall
- Associated Vitreoretinal and Uveitis Consultants, Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Antonio Caimi
- Department of Clinical Science "Luigi Sacco," Sacco Hospital, University of Milan, Milan, Italy
| | - Giovanni Staurenghi
- Department of Clinical Science "Luigi Sacco," Sacco Hospital, University of Milan, Milan, Italy
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Immunogammopathies and acquired vitelliform detachments: a report of four cases. Am J Ophthalmol 2014; 157:648-57.e1. [PMID: 24321469 DOI: 10.1016/j.ajo.2013.11.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 11/25/2013] [Accepted: 11/25/2013] [Indexed: 01/23/2023]
Abstract
PURPOSE To describe the nature and evolution of acquired macular detachments in patients with immunogammopathies and to propose a mechanism for their development. DESIGN Retrospective observational case series. METHODS Three patients with multiple myeloma and 1 with light chain deposition disease were diagnosed with vitelliform macular detachments based on clinical examination, fundus autofluorescence, fluorescein angiography, and optical coherence tomography. These patients were followed over time and their clinical examinations and imaging studies were compared and contrasted. RESULTS Three patients (5 eyes) with multiple myeloma and 1 patient (2 eyes) with light chain deposition disease presented with acquired macular yellowish subretinal deposits on funduscopic examination that corresponded to hyperautofluorescent lesions on fundus autofluorescence imaging and subretinal hyperreflective material on spectral-domain optical coherence tomography. One patient (2 eyes) had diffuse serous retinal detachments involving not only the macular region but also the midperiphery of the retina. These acquired macular vitelliform detachments were not associated with signs of hyperviscosity retinopathy in 5 eyes and resolved after successful treatment of the multiple myeloma in 6 eyes. CONCLUSION Patients with an immunogammopathy such as multiple myeloma or light chain deposition disease may develop serous elevations of the macula that we classify as acquired vitelliform detachments using multimodal imaging. Appropriate evaluation including serum protein electrophoresis and hematology consultation should be considered in the management of patients with acquired vitelliform detachments of uncertain etiology.
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Kolb SD, Dhingra N, McKibbin MA. Retinal haemorrhage, subretinal pigment epithelial deposits and serous macular detachment in light chain deposition disease. Br J Ophthalmol 2013; 97:1218-9. [PMID: 23853165 DOI: 10.1136/bjophthalmol-2013-303912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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18
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Shah AR, Zaidi A, Brucker AJ. Serous retinal detachments associated with light chain deposition disease. Retin Cases Brief Rep 2013; 7:236-241. [PMID: 25391113 DOI: 10.1097/icb.0b013e31828eeecc] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE To report the clinical, fluorescein angiography, spectral-domain optical coherence tomography, and fundus autofluorescence (AF) findings of a 64-year-old woman with systemic light chain deposition disease. METHODS Clinical examination, fundus photographs, fundus AF, spectral-domain optical coherence tomography, and fluorescein angiography before and after renal transplantation in a patient with light chain deposition disease. RESULTS The patient presented with decreased visual acuity in her right eye. Fundus examination showed bilateral drusenoid subretinal deposits associated with subretinal fluid. Fluorescein angiography showed staining of the lesions seen on clinical examination. Spectral-domain optical coherence tomography showed hyperreflective material below the neurosensory retina associated with subretinal fluid. Fundus AF showed areas of increased AF corresponding to the lesions. The lesions showed improvement after renal transplantation and initiation of immunosuppressive agents. CONCLUSION Patients with light chain deposition disease may present with subretinal deposits that can be seen clinically and demonstrated on fluorescein angiography, AF, and optical coherence tomography. They may also present with localized serious retinal detachments. Both these deposits and serous retinal detachments may improve with renal transplantation or immunosuppressive therapy.
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Affiliation(s)
- Ankoor R Shah
- Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
60 year-old man, without relevant medical history, noted a slight and progressive instability of gait for one month and right hand clumsiness. Brain MRI showed a cerebellar lesion, posterior to the middle cerebellar peduncle. This lesion was heterogeneous and hyperintense on FLAIR sequences, isointense on T1-weighted images, and showed gadolinium enhancement. Hematological and biological serum analyses were normal as were plasma and urine immunoelectrophoresis. CSF analysis including protein electrophoresis was unremarkable. CT scans of the abdomen, chest and pelvis were normal as were cervical echography and bone scintigraphy. A yellowish and firm lesion was surgically resected. The patient's recovery was good, with normal total body PET scan and bone marrow biopsy. Pathological study evidenced kappa light chain deposits and kappa-immunopositive mature plasma-cells in the vicinity. The deposits failed to show any birefringence in polarized light microscopy after Congo red staining, and electron microscopy revealed their granular ultrastructure. Light chains are well known for their amyloidogenic properties, but in a few cases, they are non amyloidogenic and may cause tissue deposits histologically similar to amyloid but Congo red-negative and non fibrillary at ultrastructural examination. Occurrence of light chain deposits in the brain is rare and the tumor-like MRI presentation is reminiscent of primary intracerebral amyloidoma presenting as a mass lesion. This is the first report of intracerebral kappa light chain deposits which presumably derived from local synthesis by mature plasma cells.
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Molina-Garrido MJ, Guillén-Ponce C, Mora A, Guirado-Risueño M, Molina MA, Molina MJ, Carrato A. Deposition-associated diseases related with a monoclonal compound. Clin Transl Oncol 2007; 9:777-83. [PMID: 18158981 DOI: 10.1007/s12094-007-0139-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Up to 3% of adults over 50 years of age show a monoclonal peak values in blood or urine. Findings and prognosis will be distinct in view of the nature of this factor. In B-cell neoplasias (multiple myeloma, Waldeström macroglobulinaemia, chronic myeloid leukaemia and non-Hodgkin lymphoma) the clinical pattern is dominated by the systemic effects produced by the expansion of the malign clone; the monoclonal protein may result in hyperviscosity syndrome or renal damage. On the other hand, there are other less frequent processes called diseases associated to monoclonal components, where the main clinical manifestations and prognosis depend of the biological effects of the monoclonal protein. With reference to this last group, which is the objective of this revision, no bone lesions, anaemia or a greater tendency to infections usually occur when compared with the first group. Even so, there are some cases of interposition between both groups: for instance, type IgM immunoglobulin present in Waldeström macroglobulinaemia may have cold agglutinin activity, and in the case of multiple myeloma, the clone may secrete amyloidogenic light chains.
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Affiliation(s)
- M J Molina-Garrido
- Oncology Department, General Universitary Hospital in Elche, Elche, Alicante, Spain.
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Kuypers DRJ, Lerut E, Claes K, Evenepoel P, Vanrenterghem Y. Recurrence of light chain deposit disease after renal allograft transplantation: potential role of rituximab? Transpl Int 2007; 20:381-5. [PMID: 17326779 DOI: 10.1111/j.1432-2277.2006.00437.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Light chain deposit disease (LCDD) is a monoclonal plasma cell disorder characterized by tissue deposition of nonamyloid immunoglobulin light chains, predominantly kappa chains, causing renal insufficiency. LCDD reoccurs almost invariably after renal grafting, leading to early graft loss, usually within a time span of months to years. We describe a female patient with LCDD who lost her first living donor graft after 1 year due to extensive recurrence of kappa chain deposition. Rituximab was administered on the seventh day after her second transplantation with a graft from a deceased donor, in order to prevent early recurrence of LCDD. The 2-year protocol biopsy - similarly to the completely normal 1-year protocol biopsy - revealed persistent absence of light chain deposition on light microscopy but immunohistochemical staining and electron microscopy showed very mild recurrence of light chain deposits. A second 4-week course of rituximab was repeated because of these electron microscopic findings. Subsequently, free kappa light chain concentration decreased from 693 to 74 mg/l and remained low 4 months after completion of therapy. Rituximab could be considered for delaying early LCDD recurrence in patients in whom treatment of the underlying bone marrow disorder failed or is contraindicated, but maintenance therapy is apparently necessary to consolidate this response.
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Affiliation(s)
- Dirk R J Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.
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Fischer L, Korfel A, Stoltenburg-Didinger G, Ransco C, Thiel E. A 19-year-old male with generalized seizures, unconsciousness and a deviation of gaze. Brain Pathol 2006; 16:185-6, 187. [PMID: 16768760 PMCID: PMC8095819 DOI: 10.1111/j.1750-3639.2006.00003_3.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Light chain deposition disease (LCDD) is a form of monoclonal immunoglobulin deposition diseases (MIDD) which in contrast to light-chain derived (AL) amyloidosis is characterized by non-congophilic, non-fibrillary monoclonal protein deposits. Systemic organ deposits are common with the kidney being a major target organ. A clonal lymphoplasmocytic proliferation, e.g. plasmacytoma, is present in the majority of cases. Here we report on a 19-year-old male who presented with generalized seizures and an enhancing white matter lesion on MRI scans. A stereotactic brain biopsy revealed a low-grade B cell lymphoma with plasmacellular differentiation as well as lambda light chain deposits without birefringence under polarized microscopy. No systemic lymphoma manifestations or systemic light chain deposits were found, nor was a monoclonal gammopathy detectable in serum and urine. After systemic chemotherapy with three courses high-dose methotrexate the size of the lesion and the condition of the patient have remained stable for 24 months now. This is the first description of cerebral LCDD developing without systemic disease in conjunction with the diagnosis of a cerebral low-grade B cell lymphoma. We present the clinical, laboratory and radiological findings and discuss the pathogenesis of this unusual LCDD manifestation.
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Affiliation(s)
- L Fischer
- Department of Hematology, Oncology and Transfusion Medicine, Klinikum Benjamin Franklin, Freie Universität, Berlin, Germany
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Abstract
PURPOSE To describe the occurrence of bilateral iris and retinal crystals in a patient with benign HIV-related gammopathy. DESIGN Observational case report. METHODS A 45-year-old HIV-positive male with a known, benign hypergammaglobulinemia was referred for routine ophthalmic assessment because of right ophthalmic zoster. RESULTS Ophthalmoscopic examination revealed the presence of bilateral, multiple, refractile iris and macular crystals. No other signs of uveitis or stigmata of HIV were found. CONCLUSION Intraocular crystals are a rare finding, usually seen in chronic uveitis with or without hypergammaglobulinemia. This finding has not been previously described in non-inflamed eyes, nor as an ocular manifestation of HIV. We hypothesize that HIV-related disruption of the blood-aqueous and blood-retinal barriers allows intraocular immunoglobulin deposition in patients with hypergammaglobulinemia.
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Affiliation(s)
- Andrew Traill
- The Royal Victorian Eye and Ear Hospital, Melbourne, Australia
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Toor AA, Ramdane BA, Joseph J, Thomas M, O'Hara C, Barlogie B, Walker P, Joseph L. Cardiac nonamyloidotic immunoglobulin deposition disease. Mod Pathol 2006; 19:233-7. [PMID: 16341150 DOI: 10.1038/modpathol.3800524] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cardiac nonamyloidotic immunoglobulin (Ig) deposition disease (CIDD) is a rare disorder characterized by Ig deposition in the myocardium associated with plasma cell dyscrasias. A retrospective review of cardiac biopsies performed at two different institutions identified eight patients with CIDD. All patients had plasma cell dyscrasias with monoclonal gammopathy. Three had IgG lambda, two had IgG kappa, one had IgD kappa and one each had free kappa and free lambda light chain. Four patients had concurrent amyloidosis involving other organs. One had amyloidosis of kidney alone, one had amyloidosis of kidney and abdominal fat pad and two others had amyloidosis of bone marrow vasculature. Three patients had dialysis-dependent renal insufficiency. None of the patients had symptoms of heart failure. Six patients had echocardiographically demonstrable concentric left ventricular hypertrophy with diastolic dysfunction. Two patients had significant cardiac arrhythmias requiring medical intervention. On endomyocardial biopsy, all eight had normal appearing myocardium on light microscopy with negative Congo Red and Thioflavin T stains. On immunofluorescent staining of the cardiac biopsies, all eight stained positive for interstitial Ig deposition. Electron microscopy (EM) confirmed the presence of granular deposits of Igs in the myocardium in five of the eight patients. EM studies were not available in one patient and two others had normal EM studies. In conclusion, CIDD should be considered in the spectrum of cardiovascular pathology in patients with plasma cell dyscrasias. They often, but not always, have left ventricular hypertrophy. These patients may be at risk for developing arrhythmias as well as diastolic dysfunction. Unless immunofluorescent and EM studies are performed routinely in biopsy material, this entity may be missed in the absence of amyloidosis. Concurrent amyloidosis in other organs sheds a unique perspective into the role of local microenvironment in the pathogenesis of systemic Ig deposition disease and amyloidosis.
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Affiliation(s)
- Amir A Toor
- Myeloma Institute for Research and Therapy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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