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Kang H, Hubbi ME. A Rare Cause of Chronic Diarrhea and Peripheral Neuropathy. Gastroenterology 2024; 166:e17-e19. [PMID: 37714363 DOI: 10.1053/j.gastro.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/10/2023] [Indexed: 09/17/2023]
Affiliation(s)
- Hansol Kang
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Maimon E Hubbi
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
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2
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Dispenzieri A. POEMS syndrome: Update on diagnosis, risk-stratification, and management. Am J Hematol 2023; 98:1934-1950. [PMID: 37732822 DOI: 10.1002/ajh.27081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 09/22/2023]
Abstract
DISEASE OVERVIEW POEMS syndrome is a life-threatening condition due to an underlying plasma cell neoplasm. The major criteria for the syndrome are polyradiculoneuropathy, clonal plasma cell disorder, sclerotic bone lesions, elevated vascular endothelial growth factor, and the presence of Castleman disease. Minor features include organomegaly, endocrinopathy, characteristic skin changes, papilledema, extravascular volume overload, and thrombocytosis. DIAGNOSIS The diagnosis of POEMS syndrome is made with three of the major criteria, two of which must include polyradiculoneuropathy and clonal plasma cell disorder, and at least one of the minor criteria. RISK STRATIFICATION Because the pathogenesis of the syndrome is not well understood, risk stratification is limited to clinical phenotype rather than specific molecular markers. Risk factors include low serum albumin, age, pleural effusion, pulmonary hypertension, and reduced estimated glomerular filtration rate. RISK-ADAPTED THERAPY For those patients with a dominant plasmacytoma, first-line therapy is irradiation. Patients with diffuse sclerotic lesions or disseminated bone marrow involvement should receive systemic therapy. Corticosteroids are temporizing, but alkylators and lenalidomide are the mainstays of treatment, the former either in the form of low-dose conventional therapy or as high-dose conditioning for stem cell transplantation. Thalidomide and bortezomib also have activity, but their benefit needs to be weighed against their risk of exacerbating the peripheral neuropathy. Daratumumab combinations also appear promising based on case series. Prompt recognition and institution of both supportive care measures and therapy directed against the plasma cell result in the best outcomes.
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Mauermann ML, Southerland AM. Hematologic Disorders and the Nervous System. Continuum (Minneap Minn) 2023; 29:826-847. [PMID: 37341332 DOI: 10.1212/con.0000000000001238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE This article discusses the epidemiology, diagnosis, treatment, and prevention of neurologic complications of red blood cell, platelet, and plasma cell disorders. LATEST DEVELOPMENTS Cerebrovascular complications can occur in patients with blood cell and platelet disorders. Treatment strategies to prevent stroke are available for patients with sickle cell disease, polycythemia vera, and essential thrombocythemia. A diagnosis of thrombotic thrombocytopenic purpura should be considered in patients with neurologic symptoms, hemolytic anemia, thrombocytopenia, mild renal insufficiency, and fever. Plasma cell disorders can be associated with peripheral neuropathy, and classification of the monoclonal protein type and neuropathy aid in diagnosis. Patients with POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, and skin changes) syndrome can present with arterial and venous neurologic events. ESSENTIAL POINTS This article discusses the neurologic complications of blood cell disorders and the most recent advances in prevention and treatment.
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Jurczyszyn A, Olszewska-Szopa M, Vesole D. POEMS Syndrome-Clinical Picture and Management. Current Knowledge. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023:S2152-2650(23)00136-2. [PMID: 37210272 DOI: 10.1016/j.clml.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/17/2023] [Accepted: 04/20/2023] [Indexed: 05/22/2023]
Abstract
POEMS syndrome is a rare form of plasma cell dyscrasia. Difficulties arise already at the stage of making the diagnosis (complex and heterogeneous clinical picture) and continue during the course of treatment (lack of guidelines for therapy, data coming mainly from reports and short series of patients). In this article we review the current state of knowledge on POEMS syndrome diagnostics, clinical characteristics, prognosis, reported treatment outcomes and the emergence of the new therapeutic strategies.
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Affiliation(s)
- Artur Jurczyszyn
- Department of Hematology, Jagiellonian University Medical College, Kraków, Poland.
| | - Magdalena Olszewska-Szopa
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | - David Vesole
- Hackensack University Medical Center, New Jersey Medical School, Rutgers University, Hackensack, NJ
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Khwaja J, D'Sa S, Lunn MP, Sive J. Evidence-based medical treatment of POEMS syndrome. Br J Haematol 2023; 200:128-136. [PMID: 35934319 DOI: 10.1111/bjh.18400] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/18/2022] [Accepted: 07/25/2022] [Indexed: 01/14/2023]
Abstract
POEMS syndrome is a rare multisystem paraneoplastic disorder due to an underlying low-level plasma cell dyscrasia. Due to its rarity, there are limited data to guide treatment and there are no consensus guidelines. Therapy choices are dictated by patient characteristics, disease factors and local funding arrangements. The goals of therapy are to eradicate the underlying clone in order to improve quality of life and overall survival. Most evidence has been garnered in the front-line setting. Localised disease responds well to radiotherapy, whilst for those with systemic disease, the best outcomes are demonstrated with induction chemotherapy followed up with high-dose melphalan and stem cell rescue if eligible. For transplant-ineligible patients lenalidomide-dexamethasone remains a preferred treatment option. Data in the relapse setting are scarce. Supportive care including management of neuropathy, endocrinopathy, thrombotic risk and anti-infective agents is necessary. Future international collaboration is crucial to define optimal treatment strategies particularly in the relapse setting.
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Affiliation(s)
- Jahanzaib Khwaja
- Department of Haematology, University College London Hospitals, London, UK
| | - Shirley D'Sa
- Department of Haematology, University College London Hospitals, London, UK
| | - Michael P Lunn
- Centre for Neuromuscular Disease, National Hospital for Neurology and Neurosurgery, London, UK
| | - Jonathan Sive
- Department of Haematology, University College London Hospitals, London, UK
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6
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Angeloudi E, Pappi E, Liakos A, Mainou M, Vlachaki E, Bekiari E. A rare case of POEMS syndrome presenting as essential thrombocythemia. Oxf Med Case Reports 2022; 2022:omac129. [PMID: 36540841 PMCID: PMC9759948 DOI: 10.1093/omcr/omac129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 08/21/2022] [Accepted: 09/26/2022] [Indexed: 12/23/2022] Open
Abstract
Polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes (POEMS) is a rare paraneoplastic syndrome, and its diagnosis is based on a series of clinical and laboratory findings. We present the case of a 46-year-old woman who was previously diagnosed with essential thrombocythemia. The patient complained about dyspnea on exertion, nausea, burning of the lower limbs, weight loss, recurrent episodes of lower back pain and polymenorrhea. Physical examination revealed hyperpigmentation, livedo reticularis of the lower limbs, sclerodermoid changes and plectrodactyly. A computed tomography-guided bone biopsy revealed the presence of plasmacytoma, and based on a combination of clinical features such as polyneuropathy, a diagnosis of POEMS syndrome has been established. The diagnosis of POEMS syndrome demands a high index of suspicion, especially in cases of peripheral neuropathy, peripheral edema or organomegaly of unknown origin. Since the syndrome can be fatal, early diagnosis is pivotal for patients' survival and quality of life.
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Affiliation(s)
- Elena Angeloudi
- Correspondence address. Second Department of Internal Medicine, Hippokration Hospital, Aristotle Univeristy of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece. Tel: +30-2310-892246; Fax: +30-2310-892246; E-mail:
| | - Eleni Pappi
- Second Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aris Liakos
- Second Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Mainou
- Second Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efthymia Vlachaki
- Second Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Bekiari
- Second Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Bou Zerdan M, George TI, Bunting ST, Chaulagain CP. Recent Advances in the Treatment and Supportive Care of POEMS Syndrome. J Clin Med 2022; 11:jcm11237011. [PMID: 36498588 PMCID: PMC9741379 DOI: 10.3390/jcm11237011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/13/2022] [Accepted: 11/25/2022] [Indexed: 11/29/2022] Open
Abstract
POEMS is a rare clonal plasma cell disorder characterized by multi-systemic features that include demyelinating peripheral neuropathy, organomegaly, endocrinopathy, presence of monoclonal proteins (M-protein), and skin changes. Even though the pathophysiology is poorly understood, recent studies suggest that both clonal and polyclonal plasmacytosis leading to the production of pro-inflammatory cytokines and angiogenic mediators play the central role. These mediators including vascular endothelial growth factor (VEGF) are the driving forces of the syndrome. The diagnosis of POEMS is not always straight forward and often the diagnosis is delayed. It is based on fulfilling mandatory criteria of polyradiculoneuropathy and monoclonal protein and the presence of one major criterion (Castleman disease, sclerotic bone lesions, or elevated VEGF), and at least one minor criterion. Due to the presence of neuropathy, it can be confused with chronic inflammatory demyelinating polyradiculopathy (CIDP), and if thrombocytosis and splenomegaly are present, it can be confused with myeloproliferative neoplasms. Due to the rarity of the syndrome, clear guidelines for treatment are still lacking. Immediate treatment targeting the underlying plasma cell proliferation results in a dramatic response in most patients. The key is early diagnosis and immediate anti-plasma cell directed therapy for the best clinical outcomes. For patients with disseminated disease as defined by bone marrow involvement or more than three osteosclerotic bone lesions, high-dose chemotherapy with autologous hematopoietic stem cell transplant (ASCT) yields durable responses and is the preferred treatment in eligible patients. For patients with localized bony disease, radiotherapy has proven to be very effective. Lenalidomide and dexamethasone is a proven therapy in patients ineligible for ASCT. In this review article, we tackle the diagnostic approach and discuss the latest treatment modalities of this rare debilitating disease.
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Affiliation(s)
- Maroun Bou Zerdan
- Department of Hematology-Oncology, Myeloma and Amyloidosis Program, Maroone Cancer Center, Cleveland Clinic Florida 2950, Weston, FL 33331, USA
- Department of Internal Medicine, SUNY Upstate Medical University Hospital, Syracuse, NY 13210, USA
| | - Tracy I. George
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Silvia Tse Bunting
- Division of Hematopathology and Flow Cytometry Laboratory, Department of Pathology, Cleveland Clinic Florida 2950, Weston, FL 33331, USA
| | - Chakra P. Chaulagain
- Department of Hematology-Oncology, Myeloma and Amyloidosis Program, Maroone Cancer Center, Cleveland Clinic Florida 2950, Weston, FL 33331, USA
- Correspondence: ; Tel.: +1-954-659-5840; Fax: +1-954-659-5810
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8
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Comprehensive Diagnosis and Management of POEMS Syndrome. Hemasphere 2022; 6:e796. [PMID: 36340912 PMCID: PMC9624442 DOI: 10.1097/hs9.0000000000000796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/03/2022] [Indexed: 12/02/2022] Open
Abstract
Polyneuropathy Organomegaly, Endocrinopathy, Monoclonal protein and Skin changes syndrome is a rare multisystem condition with a range of manifestations which are often overlooked as trivial comorbidities, until their whole triggers the possibility of the diagnosis. The diagnosis is typically delayed by 12-16 months, by which time patients can be severely disabled. There are no established consensus guidelines. We provide clinicians a comprehensive blueprint for managing POEMS from diagnostic suspicion through the work-up, selection of therapy, follow-up, and treatment of relapse based on published evidence and our large single-center experience. A multidisciplinary approach is essential including expert hematologists, neurologists, histopathologists, radiologists, and neurophysiologists. The aim of treatment is to eradicate the underlying plasma cell dyscrasia, but there are limited trial data to guide treatment decisions. Supportive care considerations include management of endocrinopathy, neuropathy, thrombosis, and infection. Response assessment is centered on clinical, neuropathy, hematological, vascular endothelial growth factor, and radiological criteria. Future clinical trials are welcomed in this setting where evidence is limited.
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Mellors PW, Kourelis T, Go RS, Muchtar E, Gertz MA, Kumar SK, Buadi FK, Kapoor P, Lacy MQ, Dingli D, Hwa Y, Fonder A, Hobbs M, Hayman S, Warsame R, Leung NR, Lin Y, Gonsalves W, Siddiqui M, Kyle RA, Rajkumar SV, Dispenzieri A. Characteristics and risk factors for thrombosis in POEMS syndrome: A retrospective evaluation of 230 patients. Am J Hematol 2022; 97:209-215. [PMID: 34822175 PMCID: PMC8738145 DOI: 10.1002/ajh.26422] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 02/03/2023]
Abstract
Thromboses are prevalent in POEMS syndrome, but few risk factors for POEMS-associated thrombosis have been identified. The objective of this study is to identify novel risk factors for POEMS-associated thrombosis. In this retrospective cohort of 230 POEMS patients, 27% developed thrombosis. Arterial events were slightly more common than venous. Stroke accounted for 26% of all thromboses and 53% of arterial events. There were differences in baseline features between the thrombosis group and the no thrombosis group, and these were driven by patients with arterial thrombosis. Risk factors for arterial thrombosis included thrombocytosis, elevated hemoglobin/hematocrit, extravascular volume overload, and splenomegaly. Hyperprolactinemia appeared to be a risk factor for venous thrombosis. The risk of thrombosis was most striking among men with elevated hemoglobin (32% vs. 5%, p < .001) and hematocrit (42% vs. 5%, p < .001) compared to men without. Most thromboses occurred prior to POEMS directed therapy, and most that occurred during therapy happened within 3 months of diagnosis. Twenty-one percent of patients with thrombosis had recurrence. In recognition of high overall rates of thrombosis in this population, all patients with POEMS syndrome should receive prophylactic antiplatelet therapy, and clinicians should consider anticoagulation in patients with risk factors for POEMS-associated thrombosis.
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Affiliation(s)
- Patrick W. Mellors
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Taxiarchis Kourelis
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America
| | - Ronald S. Go
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - Morie A. Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - Shaji K. Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - Francis. K Buadi
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - Prashant Kapoor
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - Martha Q. Lacy
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - Yi Hwa
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - Amie Fonder
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - Miriam Hobbs
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - Suzanne Hayman
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - Rahma Warsame
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - Nelson R. Leung
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - Wilson Gonsalves
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - Mustaqeem Siddiqui
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - Robert A. Kyle
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - S. Vincent Rajkumar
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - Angela Dispenzieri
- Division of Hematology, Mayo Clinic, Rochester, MN, United States of America,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America
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10
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Dispenzieri A. POEMS syndrome: 2021 Update on diagnosis, risk-stratification, and management. Am J Hematol 2021; 96:872-888. [PMID: 34000085 DOI: 10.1002/ajh.26240] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 05/14/2021] [Indexed: 01/03/2023]
Abstract
DISEASE OVERVIEW POEMS syndrome is a paraneoplastic syndrome due to an underlying plasma cell neoplasm. The major criteria for the syndrome are polyradiculoneuropathy, clonal plasma cell disorder (PCD), sclerotic bone lesions, elevated vascular endothelial growth factor, and the presence of Castleman disease. Minor features include organomegaly, endocrinopathy, characteristic skin changes, papilledema, extravascular volume overload, and thrombocytosis. DIAGNOSIS The diagnosis of POEMS syndrome is made with three of the major criteria, two of which must include polyradiculoneuropathy and clonal plasma cell disorder, and at least one of the minor criteria. RISK STRATIFICATION Because the pathogenesis of the syndrome is not well understood, risk stratification is limited to clinical phenotype rather than specific molecular markers. Risk factors include low serum albumin, age, pleural effusion, pulmonary hypertension, and reduced eGFR. RISK-ADAPTED THERAPY For those patients with a dominant plasmacytoma, first line therapy is irradiation. Patients with diffuse sclerotic lesions or disseminated bone marrow involvement and for those who have progression of their disease 3-6 months after completing radiation therapy should receive systemic therapy. Corticosteroids are temporizing, but alkylators are the mainstay of treatment, either in the form of low dose conventional therapy or high dose with stem cell transplantation. Lenalidomide shows promise with manageable toxicity. Thalidomide and bortezomib also have activity, but their benefit needs to be weighed against their risk of exacerbating the peripheral neuropathy. Prompt recognition and institution of both supportive care measures and therapy directed against the plasma cell result in the best outcomes.
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Affiliation(s)
- Angela Dispenzieri
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota USA
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11
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Bossart A, McClune B, Barrell K, Warner J, Majersik JJ. Pearls & Oy-sters: POEMS Syndrome: An Eloquent Acronym for a Rare Disease You Don't Want to Miss. Neurology 2021; 97:835-838. [PMID: 34099526 DOI: 10.1212/wnl.0000000000012325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
| | - Brian McClune
- Division of Hematology, University of Utah, Salt Lake City, UT
| | - Kelsey Barrell
- Kelsey Barrell, Department of Neurology, University of Utah, Salt Lake City, UT
| | - Judith Warner
- Judith Warner, Department of Ophthalmology , University of Utah, Salt Lake City, UT
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12
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Khouri J, Nakashima M, Wong S. Update on the Diagnosis and Treatment of POEMS (Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal Gammopathy, and Skin Changes) Syndrome: A Review. JAMA Oncol 2021; 7:1383-1391. [PMID: 34081097 DOI: 10.1001/jamaoncol.2021.0586] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Importance POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes) syndrome is a rare plasma cell disorder characterized by demyelinating peripheral neuropathy and clonal plasma cell proliferation. Clinical manifestations are believed to be associated with a surge of inflammatory and angiogenic mediators, including interleukins and vascular endothelial growth factor (VEGF), elicited by clonal and polyclonal plasma cells. The clinical manifestations of POEMS syndrome can be debilitating; therefore, early diagnosis is essential. This review discusses several aspects of POEMS syndrome and includes the most recently published findings, with a special emphasis on diagnosis and treatment strategies. Observations POEMS syndrome may be underdiagnosed because of its rarity, and it can be mistaken for chronic inflammatory demyelinating polyneuropathy; this misdiagnosis may lead to delayed therapy and progressive worsening of symptoms, especially neuropathy. Therefore, in addition to measurement of the VEGF level, patients with a monoclonal protein detected in blood and/or urine and neuropathy should be evaluated for POEMS syndrome with use of imaging to assess whether sclerotic bone lesions, effusions, and organomegaly are present. Clinical trials are scant, and treatment is largely based on small case series in which plasma cell-directed therapies, borrowed from the myeloma armamentarium, were used. High-dose melphalan and autologous hematopoietic cell transplantation may be offered to eligible patients. Lenalidomide and dexamethasone can be prescribed for patients who are ineligible for transplants. The main goals of therapy are to attain complete hematologic and VEGF responses and to reduce symptoms, although it may take up to 3 years for neurologic deficits to be ameliorated. Conclusions and Relevance POEMS syndrome should be considered in the differential diagnosis for patients who have peripheral neuropathy and paraproteinemia among other multisystem manifestations. The syndrome can be debilitating if not recognized early in its course; thus, appropriate diagnosis and treatment are important for optimal clinical outcomes.
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Affiliation(s)
- Jack Khouri
- Department of Hematology and Medical Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Megan Nakashima
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sandy Wong
- Department of Medicine, University of California, San Francisco, San Francisco
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13
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Ferro JM, Infante J. Cerebrovascular manifestations in hematological diseases: an update. J Neurol 2021; 268:3480-3492. [PMID: 33586004 PMCID: PMC8357668 DOI: 10.1007/s00415-021-10441-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 01/31/2021] [Accepted: 02/01/2021] [Indexed: 01/04/2023]
Abstract
Patients with hematological diseases often experience cerebrovascular complications including ischemic stroke, intracerebral and subarachnoid hemorrhage, microbleeds, posterior reversible encephalopathy syndrome, and dural sinus and cerebral vein thrombosis (CVT). In this update, we will review recent advances in the management of cerebrovascular diseases in the context of myeloproliferative neoplasms, leukemias, lymphomas, multiple myeloma, POEMS, paroxysmal nocturnal hemoglobinuria (PNH), thrombotic thrombocytopenic purpura (TTP), and sickle-cell disease. In acute ischemic stroke associated with hematological diseases, thrombectomy can in general be applied if there is a large vessel occlusion. Intravenous thrombolysis can be used in myeloproliferative neoplasms and sickle-cell anemia, but in other diseases, a case-by-case evaluation of the bleeding risks is mandatory. Patients with sickle-cell disease and acute stroke need very often to be transfused. In PNH, acute ischemic stroke patients must be anticoagulated. Most patients with CVT can be treated with low-molecular weight heparin (LMWH) acutely, even those with leukemias. Prevention of recurrence of cerebral thrombotic events depends on the control of the underlying disease, combined in some conditions with antithrombotic drugs. The recent introduction of specific monoclonal antibodies in the treatment of PHN and TTP has dramatically reduced the risk of arterial and venous thrombosis.
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Affiliation(s)
- José M Ferro
- Serviço de Neurologia, Departamento de Neurociências e Saúde Mental, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal. .,Faculdade de Medicina, Universidade de Lisboa, Hospital de Santa Maria, Neurology, 6th Floor, Avenida Professor Egas Moniz s/n, 1649-035, Lisbon, Portugal.
| | - Joana Infante
- Serviço de Hematologia e Transplantação de Medula, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
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