Multiple myeloma presenting as bilateral orbital proptosis

Superior Oblique Muscle Extramedullary Plasmacytoma in a Patient with Multiple Myeloma and a Review of Literature

Introduction

Multiple myeloma (MM), a plasma cell malignancy, is a systemic disease affecting various body organs. Plasmacytoma of bone and extramedullary disease (EMD) are presentations of MM. EMD is usually the sign of a more aggressive form of the disease. Herein, we report a patient with refractory MM presenting with extramedullary plasmacytoma in the superior oblique (SO) muscle.

Case Presentation

A 51-year-old female presented complaining of gradual protrusion of the left eye and ocular pain from 20 days prior. She received bone marrow transplantation 1 year prior and was on a chemotherapy regimen for MM for the past 1 year. Ocular examination revealed proptosis of the left eye and mild limitations of adduction and elevation. Orbital magnetic resonance imaging demonstrated remarkable enlargement of the left SO muscle with focal contrast enhancement. The patient underwent a biopsy and mass debulking. The histopathologic exam revealed fibromuscular tissue containing a neoplasm composed of sheets of plasmacytoid cells in a varying degree of differentiation with intervening scantly vascularized stromal components. The plasmacytoid cells were diffusely positive for a cluster of differentiation 138 (CD138), leading to a diagnosis of EMD involving the EOM and soft tissue of the orbit. The patient underwent palliative radiotherapy and a systemic workup. The PET-CT scan revealed involvement of the pelvic bone and left calf. Accordingly, the chemotherapy regimen was upgraded to reflect the aggressive nature of the disease. In the last follow-up, there was no sign of tumor reactivation in the orbital soft tissues. Unfortunately, the patient succumbed to her illness 7 months following her most recent presentation.

Conclusion

Early recognition of disease recurrence is lifesaving in MM patients; ophthalmic manifestations should be seriously considered as a sign of MM activity.

Orbital Involvement in Multiple Myeloma

PURPOSE

To characterize clinical and radiographic features, management, and outcomes of patients with orbital involvement of multiple myeloma (MM).

METHODS

A retrospective chart review identified patients with MM and orbital involvement confirmed by histopathology at a single institution between 1995 and 2021. A comprehensive literature review was performed via PubMed to identify all previously reported cases of orbital MM.

RESULTS

Retrospective review identified 7 patients (43% male, mean age 68.7 years). Presenting symptoms included proptosis and diplopia. Orbital lesions were primarily located laterally (42.8%) with associated extraocular muscle (57.1%) or lacrimal gland (42.9%) involvement. Five patients (71.4%) had a previous diagnosis of systemic MM. Six patients received chemoradiation (85.7%). All patients had improvement of orbital disease with 2 patients deceased due to disease at follow-up (mean 8.9 months). Literature review identified 111 cases (46.8% male, mean age 58.6 years). 48.6% presented with orbital disease as the first manifestation of systemic MM. Lesions were most commonly located superolaterally (20.2%) with extraocular muscle infiltration (25.2%), lacrimal gland involvement (7.2%), and orbital bony destruction (39.6%). Treatments included chemoradiation, chemotherapy, or radiation alone. Approximately half (51.4%) of patients experienced improvement in orbital disease following treatment, and 48.6% were deceased at follow-up (mean 20.1 months).

CONCLUSIONS

This study provides a new retrospective study and updated comprehensive literature review regarding orbital MM. Given its poor prognosis, characterization of orbital MM is essential for early diagnosis. Orbital MM is often unilateral, located superolaterally, and may represent the first manifestation of systemic disease. Treatment includes chemotherapy and radiation, which may improve orbital disease; however, the overall prognosis remains poor.

Bilateral Proptosis in a Case of Recurring Multiple Myeloma: Uncommon Orbital Presentation of Plasmacytoma

Multiple myeloma is a malignant plasma cell dyscrasia that may invade the orbits in extramedullary presentations. Common manifestations of orbital involvement include unilateral proptosis, injection, chemosis, diplopia, and occasionally pain. Additionally, the soft-tissue tumors associated with multiple myeloma typically cause bony destruction of adjacent structures. However, in certain patients, bilateral proptosis and a lack of bony destruction may occur. In these instances, it is important for physicians to consider patient history, presentation, and progression in order to ensure that a potentially fatal diagnosis is not missed. The reason this case is important is two-fold: 1) we describe a case of an individual with relapsing multiple myeloma presenting as bilateral proptosis and lacking bony destruction, highlighting the importance of understanding the disease process and 2) we discuss why patients with multiple myeloma may be more prone to developing tumors of the orbit in recurrent cases.

Uncommon Presentations of Multiple Myeloma

Multiple myeloma is a rare malignancy that exhibits a wide range of possible clinical presentations. In recent years, with the advent of stem cell transplantation, the prognosis of patients with multiple myeloma has been increasing. We searched the literature for reports of atypical myeloma presentations to aid clinicians in formulating differential diagnoses and to increase the number of cases diagnosed early. There have been a number of reports of early ocular symptoms, including, but not limited to, proptosis, optic neuropathy, vision loss, retinal hemorrhage, and detachment. Neurological presentations included cranial nerve palsies, vertigo related to cerebellar involvement, and diabetes insipidus related to pituitary involvement. Among gastrointestinal manifestations, there are a number of reports of multiple myeloma presenting as acute and chronic pancreatitis. Mesenteric ischemia due to amyloidosis, acute abdomen, and hepatosplenomegaly were also among reported presentations. When it comes to renal involvement, while acute renal failure and proteinuria are typical, there are reports of patients presenting with both nephritic and nephrotic forms of glomerular disease, as well as end-stage renal disease requiring dialysis. We believe that it is essential for clinicians to keep reporting atypical multiple myeloma presentations and consider it as a possible diagnosis in a patient with serious, atypical symptoms.

Proptosis and hemiplegia as an initial manifestation of multiple myeloma

Multiple myeloma (MM) is a monoclonal gammopathy, also known as the malignant proliferation of plasma cells, presenting with typical complications such as hypercalcemia, osteolytic bone lesions, anemia, renal insufficiency, and frequent infections. Central nervous system (CNS) involvement in MM in the form of parenchymal involvement is very uncommon and has been reported only in 1% of patients. CNS involvement as an initial presentation is very rare and has poor prognosis. Also specific treatment guidelines do not exist for the treatment of such patients. We present here a case of a 40-year-old female patient, with complaints of headache and left eye proptosis followed by left-sided hemiparesis, who after complete workup was diagnosed as a de novo case of stage III extramedullary MM with CNS involvement. Patient was treated with whole brain radiation followed by BCD regimen (injection of bortezomib, injection of cyclophosphamide, and tablet dexamethasone). After three cycles of chemotherapy, patient succumbed in view of consolidation and renal failure.

Orbital Metastasis of Multiple Myeloma: Case Report

A 68-year-old woman with a history of multiple myeloma presented to the clinic with pain and vision loss in her right eye. Proptosis was observed in her right eye and eye movements were restricted in all directions. Best corrected visual acuity was 3/10 in her right eye. On biomicroscopic examination, hyperemia and subconjunctival hemorrhage were present. Fundus examination of the right eye revealed optic disc edema and choroidal folds. In magnetic resonance imaging two orbital masses were detected. Based on the patient's history and ocular examination, we evaluated the masses as orbital metastasis of multiple myeloma. Palliative radiotherapy was recommended.

Use of the anterior chamber maintainer in trabeculectomy following vitrectomy

PURPOSE

To retrospectively observe the effects of anterior chamber maintainer (ACM) placement in glaucoma patients undergoing trabeculectomy following vitrectomy.

METHODS

Trabeculectomy was performed on 51 secondary glaucoma patients (51 eyes), all of whom had undergone vitrectomy. During trabeculectomy, an ACM was placed in 27 eyes (group A), but not in the remaining 24 (group B). Intra- and post-operative complications were recorded. Intraocular pressure (IOP) measurements were recorded pre-operatively and repeated post-operatively on follow up days 1, 3, and 7, and months 1, 3, 6, 12, 18, and 24. Surgical success rates were recorded.

RESULTS

Mean pre-operative IOPs of groups A and B were 32.74 ± 11.25 and 34.29 ± 9.68 mmHg, respectively. In group A, anterior chamber bleeding (two cases), and choroidal detachment and/or ciliary detachment (four cases) occurred. In group B, anterior chamber bleeding (five cases), and choroidal detachment and/or ciliary detachment (11 cases) occurred. There was a statistically significant difference between the two groups. There also was statistically significant difference in post-operative IOPs between the two groups at 12 and 24 months. The surgical success rate of group A was higher than that of group B.

CONCLUSION

ACM is effective in maintaining IOP and reducing complications during trabeculectomy following vitrectomy, thereby increasing surgical success rates.