Paraneoplastic Syndromes in Neuro-ophthalmology

PURPOSE OF REVIEW

This article discusses the varied types of paraneoplastic syndromes that commonly have neuro-ophthalmologic manifestations. Diagnostic considerations and therapeutic options for individual diseases are also discussed.

RECENT FINDINGS

Paraneoplastic syndromes can affect the afferent and efferent visual systems. Paraneoplastic syndromes may result in reduced visual acuity from retinal degeneration, alterations in melanocyte proliferation and uveal thickening, or acquired nystagmus. Ocular motor abnormalities related to paraneoplastic syndromes may present with symptoms from opsoclonus or from neuromuscular junction disease. Diagnosis remains challenging, but serologic identification of some specific antibodies may be helpful or confirmatory. Treatment, in addition to directed therapies against the underlying cancer, often requires systemic corticosteroids, plasma exchange, or immunosuppression, but some specific syndromes improve with use of targeted pharmacologic therapy.

SUMMARY

Diagnosis and therapy of paraneoplastic syndromes presenting with neuro-ophthalmic symptoms remain a challenge, but strategies are evolving and new approaches are on the horizon.

POEMS syndrome: A rare paraneoplastic presentation of spinal plasmacytoma

The acronym POEMS syndrome was coined for a unique multisystem disorder characterised by peripheral neuropathy, organomegaly, endocrinopathies, monoclonal gammopathy and skin changes. We report a male patient presenting to us with spinal plasmacytoma complicated with paraplegia. He was subsequently diagnosed to have POEMS syndrome and successfully treated with thalidomide and dexamethasone. Post treatment, he is able to ambulate independently.

[Male aged 31 years with polyneuropathy, prostration, and hypogonadism]

We present the case of a 31 year-old male patient, who presented polyneuropathy, symmetrical, ascending, and progressive, that led to prostration of eight months duration, accompanied by hypogonadism, hypothyroidism, hyperprolactinemia, and the presence of multiple erythematous nodules on the skin. The MRI showed hypointense lesions in the vertebrae T-6 and L-4 with sclerotic appearance. The bone marrow biopsy reported the presence of 12% plasma cells with A. restriction, supporting monoclonal gammopathy (plasmocytoma).

POEMS Syndrome with IgG-λ/IgA-κ Biclonal Gammopathy and Abnormal Serum Free Light Chain Ratio: a Case Report

BACKGROUND

POEMS syndrome is a rare paraneoplastic disorder with atypical plasma cell proliferation. Cases of POEMS syndrome presented with either biclonal gammopathy or an abnormal serum free light chain ratio are considered uncommon. The present authors encountered a case of POEMS syndrome with IgG-λ/IgA-κ biclonal gammopathy with dominant κ free light chain and abnormal serum free light chain ratio.

CASE

A 56-year-old man with a history of Castleman disease was suspected with POEMS syndrome and admitted for further evaluation for B-cell proliferative disease to rule out multiple myeloma. He also had a sustained tingling sensation on both feet and gait disturbance, which were compatible with diffuse peripheral sensorimotor polyneuropathy with demyelinating features. His laboratory findings revealed hyperlipidemia and hypothyroidism, and he had hypertrichosis. The results of the serum and urine protein electrophoresis seemed normal, except a very weak band at the end of the serum gamma region. Serum immunofixation electrophoresis confirmed IgG-λ and IgA-κ biclonal gammopathy, with an increased serum IgA concentration and normal levels of IgG, IgM, and IgD. Both serum free light chain κ and λ values were increased, and the κ/λ ratio was higher than normal.

CONCLUSIONS

The finding of IgG-λ/IgA-κ biclonal gammopathy and abnormal serum free light chain ratio with dominant κ clonality in our case was definitely rare. However, a primary pathogenic role of the different paraproteinemia in POEMS syndrome remains unclear. Further studies to identify better management modalities for POEMS syndrome is needed.

Efficacy of lenalidomide plus dexamethasone for POEMS syndrome relapsed after autologous peripheral stem-cell transplantation

POEMS syndrome is a rare paraneoplastic condition associated to an underlying plasmacellular dyscrasia. The pathogenesis of POEMS is poorly understood, but overproduction of VEGF, probably secreted by clonal plasma cells, is thought to be responsible for the signs and symptoms of the syndrome, and it seems to be useful for the monitoring of the response to therapy. At present, an effective therapeutic option for the patients is represented by autologous peripheral blood stem-cell transplantation (aPBSCT), although relapses have been described, and there is an important morbidity associated with this procedure. Before the implementation of aPBSCT, the clinical course of POEMS syndrome was characterized by progressive polyneuropathy potentially leading to death for respiratory failure. Given the high serum and plasma levels of VEGF observed in POEMS patients, the use of anti-angiogenetic drugs such as thalidomide and lenalidomide and other drugs with anti-VEGF and anti-TNF effect such as bortezomib have been considered to treat this syndrome. There are evidences of lenalidomide benefit in both front-line and previously treated patients, but scanty data are available about its use for relapse after aPBSCT. Here, we report the successful use of lenalidomide in a patient who relapsed after aPBSCT.

[A case of POEMS syndrome associated with Waldenström's macroglobulinemia and treated with lenalidomide]

This report deals with a 46-year-old male with Waldenström's macroglobulinemia (WM), who developed POEMS syndrome four years after diagnosis. The patient was diagnosed with WM, based on the presence of IgM-κ type monoclonal (M) protein and infiltration of lymphoplasmacytic cells identified in bone marrow aspirates. Four years later, the patient presented with progressive weakness and paresthesia of the limb extremities, and he was admitted to our hospital. Physical and neurological examination on admission revealed polyneuropathy, hepatosplenomegaly, hypothyroidism, IgM-κ M protein, leg edema, and cutaneous hyperpigmentation. He fulfilled the diagnostic criteria for POEMS syndrome. Laboratory tests showed normocytic normochromic anemia, elevated erythrocyte sedimentation rate, and increased levels of soluble IL-2 receptor, IL-6 and plasma vascular endothelial growth factor (VEGF). He was started on lenalidomide. After therapy, the leg edema and limb dysesthesia improved, and the VEGF level decreased from 608 pg/ml to 380 pg/ml. This is a very rare case of POEMS syndrome associated with WM, and is the first case treated with lenalidomide in Japan. VEGF presumably producted WM may be associated with development of POEMS syndrome.

[New treatment strategy for Crow-Fukase (POEMS) syndrome]

Crow-Fukase syndrome, also called POEMS (polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes) syndrome, is a rare cause of demyelinating and axonal mixed neuropathy with multiorgan involvement. The pathogenesis of Crow-Fukase syndrome is not well understood, but overproduction of vascular endothelial growth factor (VEGF), probably mediated by monoclonal proliferation of plasma cells, is likely to be responsible for most of the characteristic symptoms. There is no established treatment regimen. In appropriate candidates, high-dose chemotherapies with autologous peripheral blood stem cell transplantation is highly recommended, because this treatment could result in obvious improvement in neuropathy as well as other symptoms, with a significant decrease in serum VEGF levels. Indication of this treatment has not yet been established, and long-term prognosis is unclear at present. Thalidomide should be considered for patients who are not indicated for transplantation therapy. Treatments that should be considered as future therapy include lenalidomide, bortezomib, and anti-VEGF monoclonal antibody (bevacizumab).

[Crow-Fukase (POEMS) syndrome]

Crow-Fukase syndrome is also called POEMS (polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes) syndrome and is a rare cause of demyelinating and axonal mixed neuropathy with multiorgan involvement. The pathogenesis of Crow-Fukase syndrome is not well understood, but overproduction of vascular endothelial growth factor (VEGF), probably mediated by monoclonal proliferation of plasma cells, is likely to be responsible for most of the characteristic symptoms. However, other cytokines are also upregulated and could contribute to the pathophysiology of this syndrome. The etiopathophysiology of peripheral neuropathy is unclear, but VEGF may affect the blood-nerve barrier and allow some neurotoxic substances in the serum to access the nerve parenchyma, resulting in nerve demyelination. Moreover, microangiopathy due to proliferative endothelial cells and hypercoagulability may contribute to the development of neuropathy. A recent molecular biological study has shown oligoclonal usage of V(lambda) subfamily in light chain of the M-protein, suggesting that particular patterns of V(lambda) gene are associated with the development of Crow-Fukase syndrome. There is no established treatment regimen for this syndrome. In appropriate candidates, high-dose chemotherapies with autologous peripheral blood stem cell transplantation is highly recommended, because this treatment can cause obvious improvement in neuropathy as well as other symptoms, with a significant decrease in serum VEGF levels. The indication for this treatment has not yet been established, and the long-term prognosis is unclear. Potential future therapies include the administration of thalidomide or lenalidomide, and anti-VEGF monoclonal antibody (bevacizumab).

[Treatment strategy for POEMS syndrome]

POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes) is a paraneoplastic disease associated with an underlying plasma cell dyscrasia. This syndrome usually progresses slowly and can be life-threatening. No large-scale controlled study providing convincing evidence for the treatment of this rare condition has thus for been conducted. However, several lines of evidence have shown the efficacy of conventional therapies such as radiation, alkylator-based treatment, and corticosteroid therapy. Recent studies have also proposed novel therapeutic strategies such as autologous peripheral blood stem cell transplantation (auto-PBSCT) and thalidomide, lenalidomide, and bevacizumab therapies. We reviewed the current treatment strategies for POEMS syndrome and summarized them as follows; 1) Radiotherapy or surgical resection is highly effective for isolated plasmacytoma. 2) Melphalan-predonisolone administration may be a treatment option for the patients with widespread bone lesions. 3) High dose chemotherapy with auto-PBSCT is a promising novel approach that can lead to dramatic improvement particularly in patients with good systemic condition. 4) Plasma exchange and immunoglobulin treatment are not recommended. 5) Administration of thalidomide and lenalidomide may ameliorate the clinical conditions of the patients who are unable to undergo auto-PBSCT; however, this needs further confirmation. Finally, we emphasized that the efficacy of these therapies largely depends on the appropriate early diagnosis of POEMS syndrome.

[Pathology of Crow-Fukase syndrome]

Although the exact mechanisms underlying peripheral neuropathy in Crow-Fukase syndrome (CFS), also known as POEMS syndrome, remain obscure, careful scrutiny of the pathological changes in the peripheral nervous system (PNS) and systemic organs by using biopsy and autopsy materials may provide useful information regarding the pathogenesis and future therapeutics of the syndrome. In this review, previous biopsy/autopsy studies on CFS were systematically reviewed and the details of the pathological changes in the PNS and vascular system were noted. Most biopsied nerves revealed the characteristics of axonal degeneration and demyelination together; however, the nerve roots obtained at autopsy showed massive demyelination with few axonal changes. This morphological discrepancy can be interpreted as primary demyelination in the proximal PNS and secondary axonal degeneration in the distal PNS. Another histological hallmark of the syndrome is edema in the endoneurial space. Changes in the endoneurial and epineurial microvessels, including hyperplasia of endothelial cells, were occasionally observed. Endoneurial edema and microvascular changes can be attributed to the high serum concentration of vascular endothelial growth factor in this disorder, and the derangement in endoneurial homeostasis due to impaired blood-nerve barrier can be considered a possible pathomechanism underlying peripheral neuropathy in the CFS.

[Electrophysiologic aspects of Crow-Fukase (POEMS) syndrome--significance in early diagnosis and insights into the pathophysiology]

POEMS (polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes) syndrome is a rare cause of demyelinating and axonal mixed neuropathy with multiorgan involvement. The presence of polyneuropathy is mandatory for the diagnosis of POEMS syndrome, and progressive neuropathy results in the deterioration of patients' quality of life. Although the pathophysiology of nerve damage has not yet been elucidated, nerve conduction abnormalities exhibit characteristic, patterns that can be summarized by a number of features including (1) slow nerve conduction diffusely distributed in the intermediate nerve segment, (2) relatively preserved nerve conduction near the distal nerve terminals, (3) prominent axonal loss in distal lower extremity nerves, and (4) no conduction blocks. These features are useful in differential diagnosis of POEMS syndrome from chronic inflammatory demyelinating polyneuropathy (CIDP) and neuropathy associated with anti-myelin-associated glycoprotein antibody. The pathogenesis of POEMS syndrome is not well understood; however overproduction of vascular endothelial growth factor (VEGF), probably secreted by plasmacytoma, may be responsible for most of the characteristic symptoms, including neuropathy. The patterns of nerve conduction abnormalities suggest that demyelination and axonal degeneration are caused by some serum neurotoxic substances in serum that cannot access the nerve parenchyma under physiological conditions. Elevated serum VEGF level would result in increased permeability and breakdown of the blood-nerve barrier. In addition, endoneurial or perineurial vascular proliferation with altered hematocoaglabilty could partly play a role in the pathogenesis of neuropathy in POEMS syndrome.

[Crow-Fukase syndrome and VEGF]

Crow-Fukase syndrome is diagnosed based on the presence of chronic sensori-motor polyneuropathy along with other characteristic generalized symptoms denoted by the acronym of POEMS which stands for polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes. In this syndrome, the serum levels of the vascular endothelial growth factor (VEGF) are abnormally elevated, and this is a predictive factor for its diagnosis. Although the causes of CFS/POEMS remain unknown, VEGF is evidently correlated with its pathogenesis. Human glioblastoma cells are known to express VEGF. In models of CFS/POEMS, mice that are peritoneally transplanted with human glioblastomas exhibit high serum levels of VEGF, prominent edema with increased circulation volume, and pathological findings in the liver, spleen, and kidney. VEGF that is highly concentrated in platelets may be released in massive amounts due to coagulation in the peripheral tissue and may thus exert its maximal physiological effects and produce the abovementioned diffuse pathological findings. The correlation between polyneuropathy and elevated VEGF remains unclear. However, VEGF may affect the blood-nerve barrier by increased microvascular hyperpermeability, upregulated cytokines such as matrix metalloproteases may induce blood-nerve barrier breakdown and demyelination of the peripheral nerve. Furthermore, microangiopathy due to proliferative endothelial cells and hypercoagulated occlusion also affect axonal damage. Novel strategies that have recently been proposed for the management of this disease include high-dose chemotherapy combined with autologous peripheral blood stem cell transplantation (PBSCT) and molecular-targeted therapy against plasma cells and VEGF. Notably, PBSCT exerts a dramatic effect on polyneuropathy; such an effect has rarely been achieved by the previously described modalities of low-dose melphallan and steroid therapy. PBSCT is observed to induce a rapid and persistent decrease in the serum VEGF levels. In conclusion, VEGF is not only the primary molecule involved in the pathogenesis of CSF, but also an important marker for both the diagnosis and treatment of this disease.

[New strategy of treatment for POEMS syndrome--autologous peripheral blood stem cell transplantation and thalidomide therapy]

POEMS (polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes) syndrome is a rare cause of demyelinating and axonal mixed neuropathy with multiorgan involvement. This syndrome is potentially fatal; progressive neuropathy and/or massive peripheral edema or pleural effusion/ascites deteriorate patients' quality of life. Serious complications such as multiorgan failure due to capillary leak syndrome and thromboembolic events may occur, resulting in poor prognosis. The pathogenesis of POEMS syndrome is not well understood, but overproduction of vascular endothelial growth factor (VEGF), probably secreted by plasmacytoma, may be responsible for most of its characteristic symptoms. Many case reports and series have described patients who have been treated with irradiation, resection of plasmacytoma, chemotherapies, corticosteroids, plasmapheresis, and intravenous immunoglobulin infusion; however, there is no established treatment regimen. In suitable cases, high-dose chemotherapies with autologous peripheral blood stem cell transplantation is highly recommended because this treatment could result in obvious improvement in neuropathy as well as other symptoms, with a significant decrease in the serum VEGF levels. However, from pooled data of published experience, the transplant-related mortality is reported is 5%. At present, indications of this treatment have not yet been established and long-term prognosis is unclear. Treatments with thalidomide or lenalidomide, and anti-VEGF monoclonal antibody (bevacizumab) should be considered as future therapies.

[Clinical features of multiple myeloma]

The International Myeloma Working Group (IMWG) has recently proposed a new classification of asymptomatic myeloma and symptomatic myeloma. The distinction between asymptomatic and symptomatic myeloma depends on the presence or absence of the myeloma-related organ or tissue impairment (ROTI) defined by the IMWG. Based on the definition, some patients without clinical symptoms may fall into the "symptomatic" group because of insidious organ impairment by myeloma. Or others with clinical symptoms may fall into "asymptomatic" group, if no organ impairment is proven to be myeloma related. Recognition of the clinical features developed by ROTI is not only important for the diagnosis of symptomatic myeloma but also for the immediate institution of effective treatment. Immediate and proper management of the clinical features of symptomatic myeloma patients will have a great impact on quality of life and survival.

Manifestations cutanées associées aux paraprotéines: mécanismes des atteintes cutanées

Disease entities characterized by the presence of paraproteins have a variety of cutaneous manifestations. These manifestations may be classified in the following categories as a function of their mechanisms: * extracutaneous deposition of paraproteins, as in amyloidosis * intravascular paraprotein deposition, as in cryoglobulinemia * cutaneous lesions resulting from the biologic activity of paraprotein, as in patients with normolipemic xanthoma with monoclonal immunoglobulin anti-LDL activity * abnormal cytokine secretion, as in AESOP (adenopathy and extensive skin patch overlying a plasmacytoma) or POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes) syndromes * unknown mechanisms.

Dangerous small B-cell clones

The detection of a monoclonal immunoglobulin in serum or urine usually raises concerns about the size of the underlying B-cell-derived clone and possible systemic effects caused by its expansion. However, a small clone can synthesize a very toxic protein, producing devastating systemic damage and protean clinical presentations. The resulting "monoclonal component-related diseases," although difficult to diagnose, may be progressive and even fatal. The monoclonal protein can aggregate and deposit systemically as occurs in light-chain amyloidosis, monoclonal immunoglobulin deposition disease, crystal-storing histiocytosis, and monoclonal cryoglobulinemia. Alternatively, some monoclonal proteins possess antibody activity toward autogenous antigens and cause chronic cold agglutinin disease, mixed cryoglobulinemia, and peripheral neuropathies. Other humoral mediators may contribute to neuropathy in variant disorders such as the POEMS (polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes) syndrome. The clone synthesizing the noxious monoclonal proteins is often small, and sensitive techniques may be required to detect these immunoglobulins. A delay in diagnosis can allow irreversible organ damage and dramatically shorten survival. Prompt recognition of suggestive signs and symptoms should trigger a thorough diagnostic approach to reach the correct diagnosis quickly, because this is the key to effective therapy. Although the treatment of these conditions is not optimal, significant advances have been made, improving the duration and quality of life.

A stronger approach to weakness in the intensive care unit

ICU-acquired limb and respiratory muscle weakness is a common, serious ICU syndrome, increasing in frequency with prolonged ICU stay and sepsis. A systematic approach facilitates precise localization of the problem within central or peripheral nervous system. Most cases relate to critical illness polyneuropathy or myopathy or a combination of both (critical illness neuromyopathy). Within the latter entity, the relative contribution of neuropathy versus myopathy varies considerably among affected patients. Muscle enzyme testing, electromyography-nerve conduction and muscle biopsy are valuable investigative tests. Nerve biopsy is less commonly needed, but is useful when vascultis is suspected.

Le syndrome POEMS (ou syndrome de Crow-Fukase)

POEMS is an acronym for polyneuropathy, organomegaly, endocrinopathy, M-protein and skin changes. POEMS syndrome is also called Crow-Fukase syndrome, chiefly in Japan. The 5 above mentioned features are not always present at the first examination. The minimal criteria to establish the diagnosis are the presence of a demyelinating and axonal polyneuropathy associated with an IgA or IgG monoclonal gammopathy, the light chain being almost always lambda, and at least 2 of the 8 other features: sclerosing plasmocytoma, endocrinopathy, skin changes, organomegaly, Castleman's disease, anasarca, papillary edema or thrombocytosis. Among these features, only cutaneous glomeruloid angioma are specific. Ultrastructural identification of uncompacted myelin lamellae on the peripheral nerve biopsy is also a strong argument in favor of the diagnosis. An associated "osteosclerotic" bone lesion must be carefully searched, because its treatment may improve the other features of the syndrome, especially the neuropathy. Cytokines and the vascular growth endothelial factor might play a role in the pathogenesis of this rare multisystemic disorder.

[A case of Crow-Fukase syndrome with extramedullary plasmacytoma: marked clinical deterioration following a biopsy to plasmacytoma]

A 66-year-old man developed paresthesia of the distal parts of the bilateral lower limbs a week after his upper respiratory infection, followed by the weakness with the legs and paresthesia with the lip area, tongue and finger tips. Those symptoms gradually became worse to the point that he was unable to walk 10 days later. Although skin pigmentation, edema, and lymph node swelling were not found, we made a diagnosis of Crow-Fukase syndrome (CFS) because of clinical features of polyneuropathy, IgG-lambda type M proteinemia, endocrinological abnormality, elevated plasma level of vascular endothelial growth factor (VEGF) and extramedullary plasmacytoma in his abdomen. Following intravenous immunoglobulin therapy (IVIg), he showed marked improvement. However, his neurologic symptoms deteriorated acutely just after open biopsy together with the elevation of VEGF level, and a few days later he was in the state of flaccid quadriparesis. We tried IVIg therapy again and his neurologic symptoms were markedly improved. We speculated that an elevated VEGF, released from plasma cells induced by the bioprocedure, might have caused an increase in microvascular permeability and affected the blood-nerve-barrier, thereby his neurologic symptoms deteriorated. It is thought that this case may support the hypothesis that a significant role is played by VEGF in the pathomechanism of the development of CFS. Additionally we experienced that IVIg was very effective to the neurologic symptoms, and we think that IVIg will be able to be one of the future therapy of the CFS. To our knowledge, there has been no report of CFS which manifested acute deterioration of his neurologic symptoms just after open biopsy with acute onset with Guillain-Barré syndrome like symptoms.

[A case of Crow-Fukase syndrome with respiratory failure due to bilateral diaphragmatic paralysis]

A 62-year-old man with well-controlled diabetes mellitus developed numbness of the bilateral feet and hands, followed by subacutely progressive weakness and amyotrophy of extremities. He became bed-ridden state, and dyspnea also appeared, so he was referred to our hospital. Physical examination revealed a lean man, with dark-reddish skin pigmentation, crabbed fingers, bilateral pretibial pitting edema, and bristles in extremities. Thoracoabdominal paradoxical respiration was observed and pulmonary vesicular sounds was decreased markedly in the both lungs. Laboratory data revealed hypoproteinemia, abnormalities of endocrine system, but M-protein was not detected. Serum vascular endothelial growth factor level was quite high. Chest radiography revealed elevation of the bilateral diaphragm, the % vital capacity (%VC) was 24%, and arterial blood gas analysis showed marked hypoxia with hypercapnia. These findings suggested that his respiratory failure was induced by bilateral diaphragmatic paralysis caused by bilateral phrenic nerve palsy due to Crow-Fukase syndrome. He became somnolent because of hypercapnic narcosis, so non-invasive positive pressure ventilation (NIPPV) was started. We treated him with intravenous immunoglobulin and oral corticosteroids therapies, and after these therapies, his symptoms were remarkably recovered and NIPPV became unnecessary soon. The most frequent causes of respiratory failure in Crow-Fukase syndrome are pleural effusion and pulmonary hypertension, and only two cases of this syndrome with respiratory failure caused by bilateral diaphragmatic paralysis were reported until now. When the patients with Crow-Fukase syndrome complain of dyspnea, we should take the diaphragmatic paralysis into consideration, which may be improved by appropriate therapies.

[A man with plasma cell dyscrasia and polyneuropathy due to POEMS syndrome]

In a 52-year-old man with general malaise, muscle stiffness and weakness, POEMS-syndrome was diagnosed based on polyneuropathy, splenomegaly, lymphadenopathy, subclinical hypothyroidism and the presence of a monoclonal paraprotein with osteosclerotic lesions and an indurated skin (POEMS is an acronym for Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal protein, Skin changes). This is a rare systemic disease from the clinical spectrum of plasma cell dyscrasias with polyneuropathy. The clinical picture is broader and more pleomorphic than the acronym suggests. The possibility of a POEMS syndrome should be considered in the differential diagnosis of polyneuropathy in association with monoclonal gammopathy. Quite often it is associated with osteosclerotic myeloma or mixed osteoscleroticlytic lesions. The patient described was treated with high dose corticosteroids which were gradually decreased over the next three months, upon which a marked improvement could be seen. The general malaise subsided, as did the splenomegaly, and the skin became supple again.

[Vascular endothelial growth factor and Crow-Fukase syndrome]

Serum vascular endothelial growth factor (VEGF) is highly elevated in patients with Crow-Fukase syndrome (CFS) and is well correlated with the clinical manifestations of CFS. In circulating blood, VEGF is specifically stored in platelets and released during platelet aggregation. To clarify the role of VEGF in the pathomechanism of CFS, we transplanted VEGF secretion tumors in nude mice and studied the pathological findings in these mice. Prominent edema with elevated serum VEGF were found. Organomegaly was also found in liver, spleen and kidney. Pathological findings in these organs were similar to those found in autopsies of CFS patients. In peripheral nerve, mild intraneural edema was seen, however, neuropathy was not prominent. These findings suggest that elevated VEGF may be closely correlated with generalized edema (anasarca). However, it is also important to consider factors such as cytokines and other T cell functions that, in association with VEGF, may be the cause of neuropathy in CFS.

[A patient with Crow-Fukase syndrome associated with pulmonary plasmacytoma]

We here reported a 54-year-old female patient with Crow-Fukase syndrome associated with pulmonary plasmacytoma. She was found to have scattered tumor in 1990. Although the tumor had slowly grown for the last 10 years, she showed no clinical symptoms. Numbness and weakness of lower extremities began in June 1999, and she was referred to Kyoto University Hospital on Oct. 21 1999 for evaluation of progressive symptoms. She had skin pigmentation, edema of the lower extremities, lymphadenopathy, muscle weakness and sensory disturbance in a glove-and-stocking distribution. Serological examination showed monoclonal IgG-lambda gammopathy. Serum vascular endothelial growth factor (VEGF) was markedly elevated. Microscopic studies on biopsied sural nerve demonstrated mild decrease of myelinated fibers. Immunohistochemically, the pulmonary tumor was defined as an IgG (lambda type) plasmacytoma. After treatment with melphalan-prednisolone therapy, the neurological symptoms improved along with decrease of serum VEGF levels as well as the size of pulmonary plasmacytoma. This is the first report of a patient with Crow-Fukase syndrome associated with pulmonary plasmacytoma. This case suggests that growth of pulmonary plasmacytoma might have played an important role in the overproduction of VEGF and thus development of Crow-Fukase syndrome.

[POEMS syndrome]

Poems syndrome is a rare multisystemic disorder. It manifestations are Polyneuropathy, Organomegaly, Endocrinopathy, and/or Edema, Monoclonal protein and changes in the Skin. (P.O.E.M.S.) Though some bibliography make no difference with osteoesclerotic myeloma it is considered a real syndrome. The polyneuropathy is customarily severe. Although high levels of immunoglobulins has been found in the poems, it has not been isolated a specific antibody that explain the polyneuropathy even though it is strongly suspected. The organomegaly, endocrinopathy, changes in the skin and other systems and involved organs could be in relationship to products secreted by plasmatic cells. We review the physiopathology and bibliography of the Poems, especially its neurological expression its nosologic location different from osteosclerotic myeloma and a possible relationship to the Herpes Virus 8. It was crossed in Medline the terms P.O.E.M.S. and syndrome and were obtained 271 abstracts that were all examined and finally selected the bibliography considerate meaningful for the objectives. It is presented briefly a case. P.O.E.M.S. is a syndrome that is associated to multiple plasma cell dyscracia, included the osteoesclerotic myeloma. Prognosis and the treatment vary with the underlying disease. As physiopathology of this syndrome is insinuated the action of the interleukins 1-beta (IL-1 beta) and 6 (IL-6), the vascular growth endothelial factor (VGEF), the tumoral necrosis factor alpha (TNF-alpha) and antibodies anti-nerve. The P.O.E.M.S. is a syndrome with own identity. The Herpes Virus 8 may plays a key rol to uncover the Poems physiopathology.

POEMS syndrome: cicatricial alopecia as an unusual cutaneous manifestation associated with an underlying plasmacytoma

POEMS syndrome is a rare condition with cutaneous manifestations commonly including angiomas, hypertrichosis, hyperpigmentation, and thickening of the skin. We describe a male patient with a 2-year history of cervical lymphadenopathy, erythematous thickening of the skin on the neck, and progressive walking difficulties. The patient had an occipital erythema with scarring alopecia and sparse follicular pustules at the edge of the lesion. Further investigation revealed symmetric polyneuropathy, hepatosplenomegaly, monoclonal gammopathy, subclinical thyreopathy, and an osteolytic bone lesion of the skull. Histologically, a plasmacytoma with lambda cell restriction was found. The overlying skin showed marked fibrosis, with loss of hair follicles, and a plasma cell infiltrate of polyclonal origin. The cervical lymph nodes showed histologic characteristics of multicentric Castleman's disease, and the skin of the neck showed thickening and vasoproliferation. There was no evidence of further plamacytomas. After excision of the plasmacytoma and postoperative irradiation, the symptoms gradually resolved within a few months. A cicatricial lesion remained on the occiput without further folliculitis or hair loss on the rest of the scalp. This case illustrates the reactive character of POEMS syndrome as a paraneoplastic syndrome in myeloma patients.

[POEMS-Syndrome--unusual manifestation with bilateral Charcot's Joint]

HISTORY AND CLINICAL FINDINGS

A 45-year-old patient with no significant past medical history was admitted 8 weeks after minor foot trauma with injury of the left ankle joint with massive destructive arthropathy. On admission the arch of both feet was flattened and both feet showed massive painless soft tissue swelling. Due to loss of muscle strength elevation of feet and toes was reduced and there was a "stocking-like" loss of sensation of the lower extremity. The gait was ataxic. No other abnormalities were detected besides hepatomegaly and hyperhidrosis.

INVESTIGATIONS

Advanced polyneuropathy was confirmed by nerve conduction study. Laboratory tests revealed paraproteinaemia type IgG-lambda. Bone marrow biopsy, bone scan and skeletal survey did not provide additional information. Sonography confirmed hepatosplenomegaly, endocrinological work up showed impaired glucose tolerance and lowered testosterone levels. Based on these findings the diagnosis of POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M-protein and skin changes) was established.

TREATMENT AND COURSE

Plasma exchange was unsuccessful and due to worsening of the symptoms long term treatment with cyclophosphamide was started. Furthermore the patient received NSAIDs for symptomatic relief and orthopedic shoes. One year after initial presentation the patient continues to walk.

CONCLUSION

Usually neurogenic arthropathy is associated with diabetes mellitus, syringomyelia or with infections. Our report illustrates that POEMS syndrome might present with Charcot arthritis.

[Increased vascular endothelial growth factor (VEGF) is causative in Crow-Fukase syndrome]

Crow-Fukase syndrome is a rare multisystem disorder characterized by polyneuropathy, organomegaly, endocrinopathy, skin changes and M-protein. We have examined levels of vascular endothelial growth factor/vascular permeability factor (VEGF) in serum with Crow-Fukase patients. Serum VEGF levels in Crow-Fukase syndrome were about 15 to 30 times higher than control and other neurological disorders. Most of the characteristic manifestations may be well explainable by the biological function of VEGF except polyneuropathy. We examined the direct effects of VEGF on blood nerve barrier function using blood brain barrier model of rat and intraneural injection of recombinant VEGF. As the result, VEGF affected blood nerve barrier and increased microvascular permeability, thereby inducing endoneurial edema. After increasing the permeability of the blood nerve barrier by VEGF, serum components toxic to nerves such as complements and thrombins may induce nerve damage. Our results suggest that overproduction of VEGF plays an important role in the pathogenesis of Crow-Fukase syndrome.

[Recent advance in neuroimmunology]

Many important reports have been published during these several years in Japan in the field of neuroimmunology. Serum vascular endothelial factor (VEGF) levels in Crow-Fukase (POEMS) syndrome were about 15 to 30 times than those in the control subjects and other neurological disorders. The overproduction of VEGF may be relevant to the pathogenesis of most of the manifestations including neuropathy. We speculate that VEGF may affect the blood nerve barrier by increasing microvascular hyperpermeability and thereby increasing endoneural pressure subsequent to edema. In Isaacs' syndrome, voltage-gated potassium channel (VGKC) were suppressed by anti-VGKC antibodies. The patch clamp study indicate that the pathophysiology of the suppression of VGKC seems to be due to the increased degradation of VGKC. By the recent nationwide survey, the total number of HTLV-I-associated myelopathy (HAM) patients in Japan is now estimated as 1,432. A most likely pathological mechanism of HAM is that cytotoxic T lymphocytes attack the HTLV-I infected lymphocytes infiltrating the central nervous system, resulting a surrounding nervous tissue damage by bystander mechanism.

Overproduction of vascular endothelial growth factor/vascular permeability factor is causative in Crow-Fukase (POEMS) syndrome

Crow-Fukase or POEMS syndrome of polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes is a rare multisystem disorder of obscure pathogenesis that is associated with microangiopathy, neovascularization, and accelerated vasopermeability. We examined the levels of the vascular endothelial growth factor/vascular permeability factor (VEGF) in the serum and cerebrospinal fluid (CSF) from 10 patients with this syndrome. Serum VEGF levels were about 15-30 times those in control subjects or patients with Guillain-Barré syndrome (GBS), chronic inflammatory demyelinating polyneuropathy (CIDP), and other neurological disorders. The CSF VEGF levels, however, were similar to those found in GBS and CIDP. Elevated VEGF levels in the serum decreased in 7 patients with Crow-Fukase syndrome after conventional therapy. The principal isoform of VEGF in Crow-Fukase syndrome was VEGF165. Elevated VEGF was independent of M-protein. Our results suggest that the overproduction of VEGF is important in the pathogenesis of this disorder.

Neurological manifestations of malignant and non-malignant dysglobulinaemias

The main neurological manifestations associated with malignant and non-malignant dysglobulinaemias are reviewed. These disorders are classified according to topographic features, pathological changes or association with specific plasma cell disorders. The main clinical, laboratory, immunological and pathological features are summarized. Knowledge of the pathogenesis in this group of disorders has clearly increased in recent years, allowing better diagnosis and treatment.

POEMS syndrome in a patient with diabetic ketoacidosis: case report and review

POEMS syndrome is an uncommon multisystem disorder characterized by the combination of polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes. A 57-year-old man diagnosed with POEMS syndrome after presenting with diabetic ketoacidosis and characteristic skin lesions is reported. The dermatologic and systemic manifestations of this unusual syndrome are reviewed.

POEMS syndrome, steroid-dependent diabetes mellitus, erythema elevatum diutinum, and rheumatoid arthritis as extramedullary manifestations of plasma cell dyscrasia

POEMS syndrome is a rare synopsis of different multisystemic disorders (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammapathy, and skin lesions) associated with plasma cell dyscrasia. We herein report the atypical case of a 44-year-old white man presenting with glomerulopathy, POEMS syndrome, and erythema elevatum diutinum with a few-year history of non-insulin-dependent diabetes mellitus (NIDDM) and seronegative rheumatoid arthritis (RA) as early manifestations of IgAlambda multiple myeloma. The prescription of 1 mg/kg/day prednisone improved the patient's features dramatically. Skin lesions improved by the association of glucocorticoids and plasma exchange, recurred when plasmapheresis ceased, and remitted when plasma exchange was reintroduced. NIDDM requiring insulinotherapy recurred when corticoids were discontinued and remitted when prednisone was reintroduced. However, prednisone and plasmapheresis had no effect on polyneuropathy, M-paraprotein, and plasma cell dyscrasia in our patient, who developed indolent multiple myeloma a few years later. We thus concluded that POEMS syndrome, steroid-dependent diabetes mellitus, rheumatoid arthritis, RA, and skin vasculitis in our patient were triggered by plasma cell dyscrasia.

[Poems syndrome: a case report]

INTRODUCTION

The Poems syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammapathy and skin changes) is an uncommon multisystemic disorder. Usually it is a manifestation of a type of myeloma of which the chief characteristic is the presence of osteosclerotic lesions, classically seen radiologically to be single or multiple. Nowadays, not only is Poems considered to be a manifestation of osteosclerotic myeloma, but may also be seen associated with other plasma cell dyscrasias.

CLINICAL CASE

We present a case of Poems syndrome secondary to a plasmocytoma of the dorsal vertebral column in a 32 year old male negro. Initially he had sensori-motor polyneuropathy associated with other features characteristic of the syndrome (organomegaly, IgA monoclonal gammapathy and skin changes). Later he also showed signs attributed to a compressive lesion of the dorsal spinal medulla. An unusual finding in this patient was that the bony lesion was predominantly osteoclytic.

CONCLUSIONS

We briefly review the syndrome and comment on the diagnosis.

[A case of POEMS syndrome with various complications]

A 65-year old man presented with complaints of sclerosis of skin and numbness in the extremities. During last 10 year, he had developed monoclonal gammopathy, Raynaud's phenomenon, ischemic heart disease, sigmoid colon cancer, hyperkalemia, polyneuropathy and scleroderma-like skin changes. Laboratory examinations revealed a monoclonal protein (IgA-lambda) and an elevated serum level of IL-6. Subsequently a diagnosis of POEMS syndrome was made based on the clinical features and laboratory findings which were characteristic of this syndrome. Further examinations showed the presence of glomerulonephritis and brain tumor. These various complications are of great interest in understanding the pathogenesis of POEMS syndrome.

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.

[Pro-inflammatory cytokines: a pathogenic key of POEMS syndrome]

The Polyneuropathy, Organomegaly, Endocrinopathy, M protein, Skin changes (POMEMS) syndrome is a rare multisystem disorder of obscure pathogenesis, associated with osteosclerotic myeloma. Unlike multiple myeloma without neuropathy, circulating levels of proinflammatory cytokines (IL-1 beta, TNF-alpha IL-6) are increased in patients with POEMS syndrome. Sites of IL-1 beta production include lymph node and bone marrow tissues. These data support the view that pleiotropic effects of proinflammatory cytokines released secondary to a strong activation of the monocyte/macrophage system, take part in the multisystemic expression of the disease.

POEMS syndrome and Waldenström's macroglobulinaemia

A 58 year old man presented with a three year history of impotence, night sweats and ankle swelling. On examination, the patient fulfilled the diagnostic criteria for POEMS syndrome, but was unusual in that he also had underlying Waldenström's macroglobulinaemia with IgM kappa paraproteinaemia. The patient was treated with intermittent chlorambucil and made a good recovery. POEMS syndrome has been described in association with osteosclerotic myeloma and Castleman's disease. The paraprotein involved is usually IgG or IgA with lambda light chains. This case indicates that the presence of lambda light chains is not essential for the pathogenesis of POEMS syndrome. It also emphasises the diversity of plasma cell dyscrasias that can manifest as POEMS syndrome.

Multiple autoimmune manifestations in monoclonal gammopathy of undetermined significance and chronic lymphocytic leukemia

In 18 cases of monoclonal gammopathy of undetermined significance, MGUS (monoclonal gammopathy of undetermined significance), admitted for diagnosed or suspected peripheral neuropathy, 11 patients showed other co-existing autoimmune manifestations. Two had POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M-component, and skin symptoms), the others mainly endocrinopathy and polyclonal pseudolymphoma. There were 13 cases of sensorimotor neuropathy, two cases of neuritis, while neuropathy could not be confirmed in three cases. Compared with a retrospective review of autoimmunity in a randomly selected CLL (chronic lymphocytic leukemia) cohort of 115 patients, 13 out of 42 patients with clinical and/or laboratory features of autoimmunity showed co-expression of autoimmune signs, the dominating traits being Coombs positive AIHA (auto-immune hemolytic anemia), platelet autoantibodies, endocrinopathy mainly associated with the thyroid gland, serological and/or rheumatological symptoms, but only one case of sensorimotor neuropathy. Viewed from a current model of acquired autoimmunity it is perhaps not surprising that such autoimmunity is seen predominantly in patients with monoclonal gammopathy. Thus, a high concentration of cross-reacting polyreactive autoantibodies related to the M-component might be present in these patients. Furthermore, quantitative defects of the immunoglobulins including the hypogammaglobulinemia associated with M-components can presumably give rise to a defect of the anti-idiotypic network's regulation of natural autoantibodies and autoimmune manifestations in vivo. Such autoimmune manifestations, which are easily overlooked in CLL may call for additional treatment with immunosuppression and/or intravenous, polyclonal IgG.