Syndrome of plasma cell dyscrasia, polyneuropathy, and endocrine disturbances. Report of a case

Osteosclerotic "plasmocytoma" with polyneuropathy, hypertrichosis and diabetes

The combination of osteosclerosis, polyneuropathy, monoclonal immunoglobulin, hypertrichosis, serositis and a number of other symptoms is described. It seems probable that this is a special type of myeloma. Similar cases have been described in Japan and out findings are compared with the Japanese picture. The age of the patients is unusually low. The M-component in the plasma is small. There is very little Bence Jones protein in the urine and osteolytic lesions in the skull do not seem to have occurred. The polyneuropathy may improve during treatment with cytostatic drugs.

Osteosclerotic myeloma with polyneuropathy

Five cases of histologically verified plasma cell myeloma in sclerotic skeletal foci and polyneuropathy are reported. Thirty similar cases were collected from the literature. They illustrate a special form of plasma cell neoplasia. The characteristic features are osteosclerosis, polyneuropathy resembling polyradiculitis, approximately normal hemoglobin concentration, bone marrow smears and ESR, low concentration of M-protein, and absence of Bence-Jones' proteinuria. Slow progesssion of the disease is a possible additional feature. It is hypothesized that autoimmune mechanisms are involved in the pathogenesis. This hypothesis is based on the observation of circulating immune complexes, positive Waaler's reaction and relative increase in the number of circulating B-lymphocytes.

Eosinophilic globules in 3 cases of glomeruloid hemangioma of the head and neck: a characteristic offering more evidence for thanatosomes with or without POEMS

Glomeruloid hemangiomas (GHs) are glomeruli-like capillary tufts lined by endothelial cells that contain periodic acid-Schiff (PAS) positive eosinophilic globules (EGs). These hemangiomas are characteristic cutaneous manifestation of POEMS syndrome (Polyneuropathy, Organomegaly, Endocrinopathy, M-protein, and Skin changes). Hemangiomas histologically identical to GHs but not associated with POEMS have recently been designated as papillary hemangiomas. In this report, we present solitary head and neck GHs in 3 patients, 2 without POEMS, with particular attention to the characteristic EGs. We performed immunostains for hemoglobin A, kappa and lambda light chains, factor VIII-related antigen, CD31 and CD34, PAS stain after diastase digestion (PASD), and electron microscopic examinations on routinely fixed tissues containing EGs. Eosinophilic globules stained uniformly positive for PASD but only peripherally positive for hemoglobin and light chains on surfaces, with interiors negative for antigens. Factor VIII-related antigen and CD31 and CD34 confirmed cells containing EGs to be endothelial. Electron microscopic examination suggested that EGs are enlarged secondary lysosomes (thanatosomes). These features fail to support red blood cells or immunoglobulins as EG constituents. Glomeruloid hemangiomas may be vascular proliferations stimulated by endothelial cells' protein phagocytosis but not by phagocytosis of either hemoglobin-containing red blood cells or immunoglobulins. The vascular lesions in POEMS syndrome appear identical to papillary hemangioma in cases without the other syndromic manifestations.

POEMS syndrome

POEMS syndrome is a rare paraneoplastic syndrome secondary to a plasma cell dyscrasia. Recognition of the complex of a combination of peripheral neuropathy, organomegaly, endocrinopathy, monoclonal plasmaproliferative disorder, skin changes, papilledema, extravascular volume overload (peripheral edema, pleural effusions, ascites), sclerotic bone lesions, thrombocytosis, Castleman disease is the first step in effectively managing the disease. A rise in the blood levels of vascular endothelial growth factor is usually confirmatory. More than 95% of patients will have monoclonal lambda sclerotic plasmacytoma(s) or bone marrow infiltration. In patients with a dominant sclerotic plasmacytoma, first line therapy should include radiation to the lesion. Retrospective analysis and personal experience would dictate that systemic therapy be considered for patients with diffuse sclerotic lesions or absence of any bone lesion and for those who have not demonstrated stabilization of their disease 3 to 6 months after completing radiation therapy. For those patients with diffuse disease, systemic therapy is indicated. Useful approaches include therapy with corticosteroids, low dose alkylator therapy, and high dose chemotherapy with peripheral blood stem cell transplant. Until the pathogenesis is fully understood, these are the mainstays of treatment for patients with POEMS syndrome. The role of anti-VEGF therapies, immune modulatory drugs, and proteasome inhibitors has not yet been defined, but drugs with known high rates of treatment related neuropathy should not be considered as first line therapy.

POEMS syndrome: definitions and long-term outcome

The POEMS syndrome (coined to refer to polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes) remains poorly understood. Ambiguity exists over the features necessary to establish the diagnosis, treatment efficacy, and prognosis. We identified 99 patients with POEMS syndrome. Minimal criteria were a sensorimotor peripheral neuropathy and evidence of a monoclonal plasmaproliferative disorder. To distinguish POEMS from neuropathy associated with monoclonal gammopathy of undetermined significance, additional criteria were included: a bone lesion, Castleman disease, organomegaly (or lymphadenopathy), endocrinopathy, edema (peripheral edema, ascites, or effusions), and skin changes. The median age at presentation was 51 years; 63% were men. Median survival was 165 months. With the exception of fingernail clubbing (P =.03) and extravascular volume overload (P =.04), no presenting feature, including the number of presenting features, was predictive of survival. Response to therapy (P <.001) was predictive of survival. Pulmonary hypertension, renal failure, thrombotic events, and congestive heart failure were observed and appear to be part of the syndrome. In 18 patients (18%), new disease manifestations developed over time. More than 50% of patients had a response to radiation, and 22% to 50% had responses to prednisone and a combination of melphalan and prednisone, respectively. We conclude that the median survival of patients with POEMS syndrome is 165 months, independent of the number of syndrome features, bone lesions, or plasma cells at diagnosis. Additional features of the syndrome often develop, but the complications of classic multiple myeloma rarely develop.

The AESOP (adenopathy and extensive skin patch overlying a plasmacytoma) syndrome: report of 4 cases of a new syndrome revealing POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes) syndrome at a curable stage

We describe an easily recognizable and previously not individualized clinical syndrome that can reveal solitary plasmacytoma of bone. We report 4 patients with a slowly extending violaceous skin patch overlying a solitary plasmacytoma of bone, associated with enlarged regional lymph nodes. Biopsies of the cutaneous lesion and the lymph nodes were not specific, although increased dermal mucin deposition and vascular proliferation were present in all skin specimens. Three patients had associated polyneuropathy. One patient had POEMS (Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal protein, and Skin changes) syndrome at the time the plasmacytoma was diagnosed. Another patient developed POEMS syndrome, from which he died, 4 years after excision of the plasmacytoma. The 3 other patients were treated either with irradiation or with a combination of irradiation and surgery, and recovered completely, including from the associated neuropathy and/or POEMS syndrome. We suggest calling this unique and distinctive clinical presentation the for

Osteosclerotic myeloma and 'POEMS' syndrome

Metabolic bone disease is a major cause of morbidity and mortality in patients suffering from multiple myeloma. This usually results from an imbalance between the osteoclast and osteoblast activity of bone resorption and formation due to the secretion of an osteoclast-activating factor by the myeloma cells. This generally takes the form of lytic lesions, hypercalcaemia and osteoporosis but, in a minority of patients, osteosclerosis is a striking feature. In a proportion of patients with gammopathy and the osteosclerotic form of the disease, there appears to be an association with other symptom complexes including Polyneuropathy, organomegaly, endocrine changes, and skin abnormalities. This article summarizes the clinical, radiological and laboratory features of this syndrome, which is known by the acronym 'POEMS'. It is important to recognize this condition, as it carries a better prognosis than the more common lytic form of the disease and because vincristine, and agents frequently used to treat this condition, may severely exacerbate the neuropathy and should be avoided. This syndrome is also important because it may give some insight into the pathophysiology of the plasma-cell dyscrasias.

Angiofollicular lymph node hyperplasia (Castleman's disease)

This review provides a comprehensive assessment of angiofollicular lymph node hyperplasia (ALNH) or Castleman's disease including pathogenesis, clinical presentation, histomorphologic and immunophenotypic findings, laboratory results, treatment, and prognosis. A division of ALNH into clinically relevant subtypes provides a framework for the consideration of the disorder. A comprehensive search of the medical literature involving ALNH using Medline was performed. Reports judged to be significant for the understanding of the disorder were analyzed and their findings incorporated into this review. ALNH is divided into localized/unicentric ALNH and generalized/multicentric ALNH due to the profound clinical differences seen between these variants. Localized/unicentric ALNH is separated by clinical and histomorphologic criteria into hyaline-vascular (HV) and plasma-cell (PC) subtypes. Generalized/multicentric ALNH may be divided by clinical criteria into generalized/multicentric ALNH without neuropathy (non-neuropathic) and generalized/multicentric ALNH with neuropathy (POEMS-associated or neuropathic). The dichotomy between these two subtypes is not absolute, with considerable clinical overlap occurring among patients presenting with generalized disease. Immunophenotypic and molecular probe studies demonstrate clonal B-cell lymphocyte populations in some cases, particularly those with generalized/multicentric ALNH. However, the finding of clonal populations is of no value in predicting malignant clinical progression. We conclude that using this division of ALNH, patients presenting with symptoms and histomorphology consistent with ALNH can be subdivided into the appropriate category of ALNH. Localized or unicentric disease, either HV or PC subtype, has an excellent prognosis with surgery being curative in the majority of cases. Generalized or multicentric disease indicates a poor prognosis with short survival, with the neuropathic variant possessing resistance to steroids and chemotherapy and a corresponding worse prognosis.

POEMS syndrome with myocardial infarction: observations concerning pathogenesis and review of the literature

A 27-year-old white man with no significant risk factors for coronary artery disease presented with a 9-month history of progressive impotence, gynecomastia, lower extremity paresthesias, and extensive myocardial infarction and subsequently developed ulcerative proctitis. A diagnosis of POEMS syndrome was made based on the clinical presentation; additional physical findings of papilledema, clubbing, and hyperpigmentation; and laboratory findings of an immunoglobulin G M component of the lambda subtype, elevated cerebrospinal fluid protein, and typical sclerotic bone lesions. Abnormal in vitro binding of the patient's serum immunoglobulin to testicular tissue was also seen. Cardiac catheterization showed evidence of diffuse coronary artery narrowing and left ventricular wall motion abnormalities. Diffuse coronary involvement and ulcerative proctitis have not been previously described in POEMS syndrome. It is hypothesized that an abnormal immunoglobin (or fragment) is responsible for both findings. Furthermore, the detection of antitesticular autoantibodies suggests the possibility of an interaction between the antibody and Leydig cells, leading to an alteration in the synthesis and release of sex steroids and thereby explaining the gonadal failure seen in this syndrome. Long-term glucocorticoid therapy for the past 5 years has resulted in marked subjective and objective improvement.

POEMS syndrome presenting with cardiomegaly and cardiomyopathy

A rare association of multisystemic manifestations with plasma cell dyscrasia has been termed POEMS syndrome, which includes polyneuropathy, organomegaly, endocrinopathy. M-protein, and skin changes. From literature reports, organomegaly consists of hepatosplenomegaly and/or lymphadenopathy. We here present a case of POEMS syndrome that had most of the typical features of POEMS, except that organomegaly only involved the heart. The patient's multiple clinical manifestations, including cardiomyopathy, improved with chemotherapy, which is characteristic of POEMS syndrome. However, cardiomegaly or cardiomyopathy have not previously been described with POEMS. The present case suggests that cardiomegaly and cardiomyopathy may be added to the organomegaly in POEMS.

P.O.E.M.S. syndrome with complete recovery after treatment of a solitary plasmocytoma

The P.O.E.M.S. syndrome is a rare clinical entity that has been described mainly in Japan. It is characterized by a progressive polyneuropathy with raised CSF protein content, organomegaly, endocrinopathy, skin changes and plasma cell dyscrasia. We report a new documented case associated with a solitary plasmocytoma of the 12th thoracic vertebra. Immunopathological and ultrastructural studies of the peripheral nerve did not disclose any immune-specific changes. Surgery and radiation therapy of the plasmocytoma allowed a complete recovery, with a 5-year follow-up. This case report illustrates the need for serial full skeletal survey, including scintigraphy, in middle-aged patients with progressive polyneuropathy of obscure origin.

When do optic disc edema and peripheral neuropathy constitute poetry?

A patient with chronic, bilateral optic disc edema developed multiple systemic manifestations of POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes). A serum immunoelectrophoresis showed an abnormal serum IgG lambda protein, and urine immunoelectrophoresis revealed a monoclonal lambda protein plus an IgG lambda fragment. Bone survey and MRI scan revealed a sclerotic lesion of the first lumbar vertebra, and lymph node biopsy showed changes consistent with Castleman's disease. Thus, his optic disc edema was the presenting feature of the POEMS syndrome and osteosclerotic myeloma.

A case of POEMS syndrome associated with essential thrombocythaemia and dermal mastocytosis

We describe a case of POEMS syndrome presenting with the recognized features of polyneuropathy, organomegaly, endocrine abnormalities, monoclonal protein, skin changes and anasarca. The patient was found to have both a solitary sclerotic plasmacytoma of the pelvis and evidence of Castleman's disease of lymph nodes. A number of unusual and unique features are also documented. Histological examination of affected skin demonstrated changes similar to urticaria pigmentosa including local oedema and mast cell infiltration. There was marked thrombocythaemia which has been seen in only one previous case and in addition the patient developed diffuse vascular calcification in the absence of recognized aetiological factors. Radiotherapy of the pelvic lesion and chemotherapy to control the myeloproliferative disorder gave rise to significant improvement in neuropathy. Control of anasarca required steroid therapy in addition to diuretics. The significance of these observations is discussed in relation to previous reports.

Plasma cell dyscrasia: a case of POEMS syndrome with a unique dermatologic presentation

POEMS (polyneuropathy, organomegaly [hepatosplenomegaly or lymphadenopathy], endocrinopathy, M protein, and skin changes) syndrome is an uncommon plasma cell dyscrasia with diverse manifestations, including lymphadenopathy as well as those that comprise the acronym. Dermatologic changes may include hyperpigmentation, thickened skin, hypertrichosis, and papular angiomas. These changes are believed to result from humoral products of the plasma cell clone and frequently resolve with treatment of the neoplasm. We describe a man with typical POEMS syndrome with a unique skin lesion: a large, sharply circumscribed, pigmented plaque on the anterior chest wall centered over a plasmacytoma of the sternum. Results of histologic examination showed a proliferation of capillaries of varying size, enlarged fibroblasts, and increased amounts of collagen and proteoglycan from the dermis to the periosteum. Because the outer cortex of the sternum was eroded, peptide mediators of vascular and fibroblast proliferation may have diffused directly from the plasma cell lesion into the tissues of the chest wall.

POEMS syndrome associated with polycythemia vera

POEMS syndrome is a multisystem disorder associated with polyneuropathy, organomegaly, endocrinopathy, a monoclonal protein (M-protein), and skin changes. The authors describe a patient with POEMS syndrome who has polyneuropathy of the upper and lower extremities, splenomegaly, impotence, IgA-lambda monoclonal protein (M-protein), and marked thickening of his skin. In addition, he has polycythemia vera. Although myeloproliferative disorders have been reported to occur in association with multiple myeloma, they have not been described with POEMS syndrome. The possible etiology of this association is discussed. This patient was successfully treated with melphalan and prednisone at the time of his initial diagnosis, but relapsed 10 years later. The relapse was treated with pulse doses of prednisone alone with complete resolution of his polyneuropathy and skin changes. This was accompanied by a fall in his IgA levels and improvement of his polycythemia.

Peripheral neuropathy associated with Castleman's disease

Four patients with polyneuropathy complicating the plasma cell variant of Castleman's disease (angiofollicular lymph node hyperplasia) are described. The neuropathy was predominantly motor and severely disabling. Vasculopathy, papilloedema, organomegaly, endocrinopathy, oedema and paraproteinaemia were variably present in these patients. Sural nerve biopsy showed changes of both demyelination and axonal loss. Capillary proliferation and endothelial hypertrophy in the epineurium and endoneurium, similar to that seen in affected lymph nodes, suggested that a diffuse vasculopathy may contribute to the neuropathy. Serum antibody activity against a variety of neural antigen preparations was not detected in any of the patients. Two untreated patients died. Substantial improvement in the neuropathy occurred in the two patients treated with cyclophosphamide and prednisolone.

Refractory ascites due to POEMS syndrome

A 52-yr-old woman developed exudative ascites 2 yr after the onset of peripheral neuropathy. Extensive evaluation revealed that the patient had no underlying liver disease, malignancy, infection, or cardiac or renal disease. The ascites initially responded to high-dose corticosteroid therapy. The patient had many clinical features of the recently described POEMS syndrome, including a persistent IgA lambda-paraprotein. Initially, her ascites responded to treatment with steroids. This is characteristic of the syndrome and should be considered in patients with POEMS syndrome and refractory ascites.

The skin changes of POEMS syndrome

POEMS syndrome is a multi-system disorder characterized by polyneuropathy, organomegaly, endocrinopathy, the presence of monoclonal protein and skin changes. We describe a case with scleroderma and angiomatous vascular proliferation as skin alterations which may be involved in this syndrome.

POEMS syndrome. Study of a patient with proteinuria, microangiopathic glomerulopathy, and renal enlargement

We studied a patient with POEMS syndrome (plasma cell dyscrasia with polyneuropathy, organomegaly, endocrinopathy, monoclonal [M]-protein, skin changes) who was also found to have renal enlargement and microangiopathic glomerulopathy. The latter finding is unusual in POEMS syndrome patients, and the associated symptoms can lead to confusion in diagnosis. We emphasize the importance of considering POEMS syndrome in the differential diagnosis of patients who have unexplained neuropathy, scleroderma-like skin changes, and/or monoclonal gammopathy.

Glomerular lesions associated with the Crow-Fukase syndrome

Three cases of the Crow-Fukase syndrome without radiographic changes of multiple myeloma are reported, with special reference to the glomerular changes seen. Proteinuria was detected in one case, although decreased renal function was observed in all (GFR: 41.0, 62.0, 74.1 ml/min respectively) at the time of renal biopsy. Glomerular changes were similar in all three cases. The main characteristic changes were mesangial proliferation and thickening of the glomerular capillary walls. Pictures by light microscopy were therefore similar to that of MPGN. On electron microscopy, the thickened capillary walls showed circumferential mesangial interposition and the subendothelial zone was electron-lucent and contained small dense granules or flocculent deposits. By immunofluorescent microscopy, no immunoglobulins, complement components or light chain were detected in the glomeruli except in one case.

Plasmacytoma of lymph node. Recurrent lymphadenopathy terminating in plasma cell dyscrasia with polyneuropathy and endocrine disturbances

A case with lymphadenopathy of the left side of the neck in a 38-year-old male is described. He had a history of several relapses of about 10 years duration. Swollen lymph nodes were histologically similar to those of the hyaline-vascular type of Castleman's disease, but contained clear-cut lymph sinus and a sheet-like proliferation of plasma cells. Lymph follicles showed proliferation and atrophic germinal centers, in which cellular hypertrophy in the wall of ramifying small blood vessels, called angiosclerosis, was frequently encountered. During its progress, the patient developed plasmacytoma of the lymph nodes with varied clinical manifestations such as polyneuropathy, disturbance of gait, unusual perspiration, hirsutism, gynecomastia, bilateral papilledema, and albumino-cytologic dissociation in cerebrospinal fluid.

Peripheral neuropathy in osteosclerotic myeloma: clinical and electrodiagnostic improvement with chemotherapy

A patient with a severe remote-effect polyneuropathy and other paraneoplastic features of osteosclerotic myeloma improved dramatically with melphalan and prednisone treatment. Serial electrodiagnostic studies provided an objective means of following the response to therapy and documented the improvement. We believe this represents the first reported patient with multifocal osteosclerotic myeloma and a myelomatous polyneuropathy responding to melphalan and prednisone.

The Japanese plasma cell dyscrasia syndrome: case report and theory of pathogenesis

A 54-year-old man developed pigmentation, clubbing, weight loss, oedema, hepatomegaly, lymphadenopathy, cold intolerance, hypotonia and hyporeflexia. Dominant laboratory findings were increased marrow plasma cells with IgA lambda paraproteinaemia, hypothyroidism, hyperprolactinaemia, hyperoestrogenaemia and biopsy-proven peripheral neuropathy. The clinical features and dramatic response to corticosteroids are consistent with the syndrome of plasma cell dyscrasia, polyneuropathy and endocrinopathy found predominantly in Japan. In our patient, immunofluorescence of neural tissues revealed paraprotein deposition. Although the pathogenesis is unknown, these multisystemic features may result from antibody activity or tissue deposition of paraprotein. Furthermore, the endocrinopathy may be localized at the hypothalamic level.

Solitary myeloma: clinical and prognostic features of a review of 114 cases

Within plasma cell disorders, solitary myeloma is rare as compared with multiple myeloma. In order to evaluate their relationship, the clinical findings for 114 patients with solitary myeloma were compared with those for 70 patients having classic multiple myeloma. The period of follow up ranged from a few weeks to twenty-four years, and 68.5% of those with solitary myeloma alive at ten years. Although only 23% of patients with solitary myeloma had local or widespread recurrence after two years, at ten years 85% had experienced disease progression. Comparison of the 85% with disease progression with patients with multiple myeloma revealed that solitary myeloma occurred at a younger age (mean 52.1 years), more frequently in men (60.5%), less commonly with initial spinal involvement (61.8%), but more commonly with neurologic problems associated with spinal involvement (25%), and that much more commonly, no monoclonal component was detectable in serum and/or urine at the time of initial diagnosis (82.5%). There were only two significant differences between those patients with (85%) and without (15%) progression at ten years; the patients were younger (mean, 45.7 years) and spinal involvement (26.7%). However, was less common among patients without progression, and component monoclonal always disappeared following treatment with surgery and/or radiation therapy. It is thus concluded that solitary myeloma and multiple myeloma are clearly different clinical entities; however, most patients with solitary myeloma do eventually have multiple myeloma.

Peripheral neuropathy and plasma cell neoplasias: a report of 10 cases

Ten patients with peripheral polyneuropathy associated with plasma cell neoplasias are reported. Progressive sensorimotor polyneuropathy was the presenting complaint in all patients. CSF protein concentration was elevated in most patients. The electrophysiological and pathological changes were consistent with a primary segmentary demyelinating disease. All patients were male and younger than the average patient with myeloma. None presented with high tumour mass or overt multiple myeloma. Six were affected with single or multiple plasmacytomas with osteolytic lesions. Unusual haematological features such as polycythaemia, thrombocytosis and lymphadenopathy were often combined with the polyneuropathy. Skin hyperpigmentation, gynaecomastia and diabetes mellitus were noted in some patients. Complete recovery of the polyneuropathy was observed in some patients after either cyclophosphamide and corticosteroid therapy or radiotherapy of localized plasmacytoma, suggesting a direct relationship between the plasmacytic proliferation and the neuropathy. The nature of the postulated factor produced by the plasma cells and responsible for nerve injury is discussed and the importance of a careful search for plasma cell proliferation in men with obscure polyneuropathies is outlined.

Plasma cell dyscrasia with polyneuritis and dermato-endocrine alterations. Report of a new case outside Japan

A new syndrome has been described comprising polyneuropathy, oedema, hyperpigmentation and thickening of the skin, gynaecomastia in males and amenorrhoea in females, monoclonal gammopathy, papilloedema and diabetes. There is frequent osteosclerosis with or without plasmacytoma, hepatosplenomegaly and polycythaemia. There is a good response to corticosteroids, immunosuppressive drugs and occasionally to excision or irradiation of the plasmacytoma. This syndrome was first described in Japan, and is still seen predominantly there, and only occasionally in other areas. An example in a 51-year-old Spanish female is described: she had a spectacular response to prednisone and melphalan. The aetiopathogenic possibilities are discussed.

Unusual presentations of multiple myeloma

Multiple myeloma has many unusual manifestations, which may obscure the true cause and delay proper treatment. Physicians in all specialties should be alert to this possibility, since myeloma may be at the root of such diverse disorders as carpal tunnel syndrome, peripheral neuropathy, solitary lytic bone lesions, hypercalcemia, and hyperviscosity syndrome.