In vivo confocal microscopy of verticillata-like paraproteinemic keratopathy in a patient with monoclonal gammopathy of uncertain significance evolving into smoldering multiple myeloma

Purpose

To highlight the utility of in vivo confocal microscopy (IVCM) in the microstructural characterization of corneal deposits resembling vortex keratopathy in a case of secondary deposition keratopathy due to an evolving monoclonal gammopathy.

Observations

A 56-year-old Caucasian woman previously diagnosed with monoclonal gammopathy of undetermined significance (MGUS), exhibited bilateral diffuse sub-epithelial and anterior stromal opacities distributed in a whorl-shaped pattern. IVCM examination permitted analysis of the microstructural features and distribution of the opacities in different corneal layers. Deposits resembling those reported in multiple myeloma rather than MGUS were detected, and the patient's hematologist was subsequently advised to re-evaluate the earlier diagnosis. Two months later, a bone marrow biopsy led to a diagnosis of plasma cell myeloma.

Conclusions and importance

It is suggested that cornea verticillata-like paraproteinemic keratopathy (PPK) in MGUS might be predictive of disease evolution to plasma cell myeloma. Characteristic deposits and morphological features revealed by IVCM may be helpful for non-invasive assessment or screening in patients with hematological disorders.

Increased microcirculation detected by dynamic contrast-enhanced magnetic resonance imaging is of prognostic significance in asymptomatic myeloma

This prospective study aimed to investigate the prognostic significance of dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) as a non-invasive imaging technique delivering the quantitative parameters amplitude A (reflecting blood volume) and exchange rate constant kep (reflecting vascular permeability) in patients with asymptomatic monoclonal plasma cell diseases. We analysed DCE-MRI parameters in 33 healthy controls and 148 patients with monoclonal gammopathy of undetermined significance (MGUS) or smouldering multiple myeloma (SMM) according to the 2003 IMWG guidelines. All individuals underwent standardized DCE-MRI of the lumbar spine. Regions of interest were drawn manually on T1-weighted images encompassing the bone marrow of each of the 5 lumbar vertebrae sparing the vertebral vessel. Prognostic significance for median of amplitude A (univariate: P < 0·001, hazard ratio (HR) 2·42, multivariate P = 0·02, HR 2·7) and exchange rate constant kep (univariate P = 0·03, HR 1·92, multivariate P = 0·46, HR 1·5) for time to progression of 79 patients with SMM was found. Patients with amplitude A above the optimal cut-off point of 0·89 arbitrary units had a 2-year progression rate into symptomatic disease of 80%. In conclusion, DCE-MRI parameters are of prognostic significance for time to progression in patients with SMM but not in individuals with MGUS.