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Hu H, Huang D, Ji M, Zhang S. Multiple myeloma with primary amyloidosis presenting with digestive symptoms: A case report and literature review. Arab J Gastroenterol 2020; 21:54-58. [PMID: 32088163 DOI: 10.1016/j.ajg.2020.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 05/29/2018] [Accepted: 01/26/2020] [Indexed: 12/11/2022]
Abstract
We present a case of multiple myeloma with primary systemic amyloidosis presenting with digestive symptoms in a 32-year-old male. Initial symptoms included upper abdominal discomfort for 4 months, and stool with mucous and blood for 1 month. Erosive gastritis, Helicobacter pylori infection, haematochezia, and weight loss were noted, but without bone pain, anaemia, or hypercalcaemia. Bone marrow examination showed 18.5% mature monoclonal plasma cells that were λ light chain protein and CD38 positive. Three courses of 28-day PTD therapy (i.e., bortezomib, dexamethasone, and thalidomide) were administered. Gastrointestinal symptoms and laboratory parameters improved. Post-treatment follow-up showed 0.5% plasma cells with normal morphology in bone marrow, urine λ light chain 10.1 mg/L, and negative M protein. Nevertheless, the patient died of multiple organ system failure 8 months after treatment. CONCLUSIONS: Amyloidosis is an uncommon finding in patients with multiple myeloma, especially in younger individuals.
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Affiliation(s)
- Haiyi Hu
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Yong'an Road, No. 95, Beijing 100050, China
| | - Dayong Huang
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Yong'an Road, No.95, Beijing 100050, China
| | - Ming Ji
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Yong'an Road, No. 95, Beijing 100050, China
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Yong'an Road, No. 95, Beijing 100050, China.
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2
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Iosif E, Rees C, Beeslaar S, Shamali A, Lauro R, Kyriakides C. Gastrointestinal bleeding as initial presentation of extramedullary plasma cell neoplasms: A case report and review of the literature. World J Gastrointest Endosc 2019. [DOI: 10.4253/wjge.v11.i4.309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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3
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Iosif E, Rees C, Beeslaar S, Shamali A, Lauro R, Kyriakides C. Gastrointestinal bleeding as initial presentation of extramedullary plasma cell neoplasms: A case report and review of the literature. World J Gastrointest Endosc 2019; 11:308-321. [PMID: 31040892 PMCID: PMC6475702 DOI: 10.4253/wjge.v11.i4.308] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 03/27/2019] [Accepted: 04/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Plasma-cell neoplasms rarely involve the gastrointestinal tract and manifest as gastrointestinal bleeding. Plasmablastic myeloma is an aggressive plasma cell neoplasm associated with poor outcomes. A small number of cases with gastrointestinal involvement is reported in the literature and therefore high index of suspicion is essential for avoiding delays in diagnosis and treatment.
CASE SUMMARY Our aim is to present our experience of a 70-year-old patient with a secondary presentation of plasmablastic myeloma manifesting as unstable upper gastrointestinal bleeding and to review the literature with the view to consolidate and discuss information about diagnosis and management of this rare entity. In addition to our case, a literature search (PubMed database) of case reports of extramedullary plasma cell neoplasms manifesting as upper gastrointestinal bleeding was performed. Twenty-seven cases of extramedullary plasmacytoma (EMP) involving the stomach and small bowel presenting with upper gastrointestinal bleeding were retrieved. The majority of patients were males (67%). The average age on diagnosis was 62.7 years. The most common site of presentation was the stomach (41%), followed by the duodenum (15%). The most common presenting complaint was melena (44%). In the majority of cases, the EMPs were a secondary manifestation (63%) at the background of multiple myeloma (26%), plasmablastic myeloma (7%) or high-grade plasma cell myeloma (4%). Oesophagogastroscopy was the main diagnostic modality and chemotherapy the preferred treatment option for secondary EMPs.
CONCLUSION Despite their rare presentation, upper gastrointestinal EMPs should be considered in the differential diagnosis of patients with gastrointestinal bleeding especially in the presence of systemic haematological malignancy.
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Affiliation(s)
- Evangelia Iosif
- Department of Gastrointestinal Surgery, Frimley Park Hospital, Frimley, Camberley GU16 7UJ, United Kingdom
| | - Clare Rees
- Department of Haematology, Frimley Park Hospital, Frimley, Camberley GU16 7UJ, United Kingdom
| | - Salome Beeslaar
- Department of Histopathology, Frimley Park Hospital, Frimley, Camberley GU16 7UJ, United Kingdom
| | - Awad Shamali
- Department of Gastrointestinal Surgery, Frimley Park Hospital, Frimley, Camberley GU16 7UJ, United Kingdom
| | - Roberto Lauro
- Department of Gastrointestinal Surgery, Frimley Park Hospital, Frimley, Camberley GU16 7UJ, United Kingdom
| | - Charis Kyriakides
- Department of Gastrointestinal Surgery, Frimley Park Hospital, Frimley, Camberley GU16 7UJ, United Kingdom
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4
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Comba IY, Torres Luna NE, Cooper C, W Crespo M, Carilli A. A Rare Case of Extramedullary Plasmacytoma Presenting as Massive Upper Gastrointestinal Bleeding. Cureus 2019; 11:e3993. [PMID: 30972272 PMCID: PMC6443515 DOI: 10.7759/cureus.3993] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Gastrointestinal (GI) involvement by multiple myeloma is a rare entity. Clinical manifestations depend on the site and extent of involvement. GI bleeding, obstruction, and perforation can complicate the disease course. We report a rare case of an extramedullary plasmacytoma ulcerating through the gastric mucosa and presenting as a massive upper GI bleed, which was controlled surgically with en-bloc resection of the mass infiltrating the stomach, distal pancreas, and spleen. To our knowledge, this is the first case of immunoglobulin A (IgA) myeloma with multiple GI organ involvement presenting with massive upper GI bleeding.
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Affiliation(s)
- Isin Y Comba
- Internal Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Nancy E Torres Luna
- Internal Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Christopher Cooper
- Internal Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Maria W Crespo
- Pathology, Osceola Regional Medical Center, Kissimmee, USA
| | - Allison Carilli
- Oncology, University of Central Florida College of Medicine, Orlando, USA
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den Braber-Ymker M, Heijker S, Lammens M, Croockewit S, Nagtegaal ID. Intestinal involvement in amyloidosis is a sequential process. Neurogastroenterol Motil 2018; 30:e13469. [PMID: 30230124 DOI: 10.1111/nmo.13469] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/10/2018] [Accepted: 08/14/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Gastrointestinal amyloidosis causes dysmotility. A comprehensive histological analysis to explain these symptoms is lacking. Therefore, we systematically examined histological features of intestinal dysmotility in patients with AL and AA amyloidosis, compared to controls. METHODS Autopsy tissue material from small bowel and colon was used for histological (semiquantitative) evaluation of the mucosa, blood vessels, muscular layers, enteric nervous system (ENS) and the interstitial cells of Cajal (ICC), using hematoxylin and eosin, periodic acid Schiff, Elastic von Gieson and Congo red staining, and immunohistochemistry with α-smooth muscle actin, HuC/D, S100 and CD117 antibodies, according to guidelines of the Gastro 2009 International Working Group. KEY RESULTS Amyloid deposits were present in the vascular walls of all amyloidosis patients. In the mucosa, amyloid was found in 67% of AA patients. The muscular layers were involved in 64% of amyloidosis patients, most prominent in AA patients, associated with the presence of polyglucosan inclusion bodies, but not with either abnormal α-actin patterns or fibrosis. Amyloid in the muscularis propria surrounding the myenteric plexus was found, but not inside the myenteric plexus. These deposits might be related to loss of the ICC network, but there was no association with decreased neuronal or nerve fiber density. CONCLUSIONS & INFERENCES We hypothesize that intestinal dysmotility in amyloidosis patients is a sequential process: amyloid deposition starts in the vasculature, followed by involvement of the muscular layers, ICC loss, and potentially affect the myenteric plexus. This final stage may be accompanied by clinical symptoms of severe intestinal dysmotility.
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Affiliation(s)
| | - Sanneke Heijker
- Department of Pathology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Martin Lammens
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pathology, Antwerp University Hospital, University of Antwerp, Edegem, Belgium.,MIPRO, University of Antwerp, Antwerp, Belgium
| | - Sandra Croockewit
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
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Zhou HB. A case of multiple myeloma initially presenting as hematemesis. TURKISH JOURNAL OF GASTROENTEROLOGY 2018; 29:108-111. [PMID: 29391314 DOI: 10.5152/tjg.2018.17710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
A few cases of multiple myeloma with gastrointestinal bleeding have been reported, but hematemesis is rarely encountered as an initial symptom of multiple myeloma. Here we report a case of multiple myeloma with an initial symptom of hematemesis. Gastroscopy revealed ulceration in the angulus of the stomach. Colonoscopy revealed many ulcers in the ascending colon. A definite diagnosis of gastrointestinal amyloidosis was made using tissue biopsy. A definite diagnosis of multiple myeloma was made using bone marrow puncture. Hematemesis may be an initial symptom of multiple myeloma. A diagnosis of amyloidosis-induced hematemesis should be considered in patients with multiple myeloma.
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Affiliation(s)
- Hai Bo Zhou
- Department of Gastroenterology, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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7
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Iida T, Yamano H, Nakase H. Systemic amyloidosis with gastrointestinal involvement: Diagnosis from endoscopic and histological views. J Gastroenterol Hepatol 2018; 33:583-590. [PMID: 28940821 DOI: 10.1111/jgh.13996] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 09/12/2017] [Accepted: 09/12/2017] [Indexed: 12/13/2022]
Abstract
Amyloid tends to deposit in the gastrointestinal tract, which, being easily accessible, is often the target organ for a pathological diagnostic examination. Although a mucosal biopsy is necessary for a definitive diagnosis and several studies have reported positive results for each possible biopsy site, there remain many unclear features in various aspects. This review focuses on the current literature to determine a better understanding of the diagnosis from endoscopic and histological views in patients with systemic amyloidosis with gastrointestinal involvement. A literature search was performed using PubMed to identify relevant studies; linked references were also reviewed. Endoscopic findings vary based on the organ and the depositing amyloids. A fine granular appearance or polypoid protrusions are likely to occur in the duodenum. AL, Aβ2M, and ATTR amyloids are likely to deposit submucosally, while AA amyloid is easily deposited in the superficial layer of the mucous membrane. Furthermore, it is necessary to consider the collection of biopsy specimens from the duodenum, which has high positive biopsy rates. However, the difference in the positive biopsy rates depends on whether endoscopic findings are available or whether the appropriate number has not been fully elucidated. A duodenal biopsy is strongly recommended to confirm the deposition of amyloid in patients with systemic amyloidosis having gastrointestinal involvement. Because amyloidosis is a disease with a poor prognosis, early diagnosis and treatment are required; gastroenterologists and endoscopists play important roles.
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Affiliation(s)
- Tomoya Iida
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Hiroo Yamano
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
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8
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Amyloidosis of the gastrointestinal tract and the liver: clinical context, diagnosis and management. Eur J Gastroenterol Hepatol 2016; 28:1109-21. [PMID: 27362550 DOI: 10.1097/meg.0000000000000695] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Amyloidosis is a group of disorders that can manifest in virtually any organ system in the body and is thought to be secondary to misfolding of extracellular proteins with subsequent deposition in tissues. The precursor protein that is produced in excess defines the specific amyloid type. This requires histopathological confirmation using Congo red dye with its characteristic demonstration of green birefringence under cross-polarized light. Gastrointestinal (GI) manifestations are common and the degree of organ involvement dictates the symptoms that a patient will experience. The small intestine usually has the most amyloid deposition within the GI tract. Patients generally have nonspecific findings such as abdominal pain, nausea, diarrhea, and dysphagia that can often delay the proper diagnosis. Liver involvement is seen in a majority of patients, although symptoms typically are not appreciated unless there is significant hepatic amyloid deposition. Pancreatic involvement is usually from local amyloid deposition that can lead to type 2 diabetes mellitus. In addition, patients may undergo either endoscopic or radiological evaluation; however, these findings are usually nonspecific. Management of GI amyloidosis primarily aims to treat the underlying amyloid type with supportive measures to alleviate specific GI symptoms. Liver transplant is found to have positive outcomes, especially in patients with specific variants of hereditary amyloidosis.
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9
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Perforation of the sigmoid colon and massive ischemia of the small intestine caused by amyloidosis associated with multiple myeloma: a case report. Int Surg 2016; 99:685-90. [PMID: 25437571 DOI: 10.9738/intsurg-d-14-00058.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Amyloidosis is a metabolic disease that results in organ dysfunction because of the deposition of amyloid proteins in body tissues and organs. Amyloid accumulation in the gastrointestinal tract can lead to severe complications with poor outcomes. We report a case showing simultaneous perforation of the sigmoid colon and massive segmental intestinal ischemia caused by amyloidosis associated with multiple myeloma. A 75-year-old woman presented to the emergency department in our hospital with a chief complaint of abdominal pain. Results of several examinations indicated sigmoid colon perforation and acute generalized peritonitis. She underwent an emergency exploratory laparotomy. Operative finding was a perforation of the sigmoid colon and many segmental discoloration sites appeared intraoperatively in the small intestine. A loop colostomy was performed by employing a double-barrel ileostomy with a massive resection of the segmentally discolored small bowel. Pathological findings suggested that the causative factor was amyloidosis with multiple myeloma. The patient was successfully treated with adequate surgery and with melphalan and prednisone after the operation. Meticulous and appropriate treatment for severe complications involving amyloidosis associated with multiple myeloma can prevent a fatal outcome.
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10
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Kim SB, Kim KO. [Lower gastrointestinal bleeding induced by secondary amyloidosis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2015; 64:387-9. [PMID: 25675542 DOI: 10.4166/kjg.2014.64.6.387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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11
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Gjeorgjievski M, Purohit T, Amin MB, Kurtin PJ, Cappell MS. Upper Gastrointestinal Bleeding from Gastric Amyloidosis in a Patient with Smoldering Multiple Myeloma. Case Rep Gastrointest Med 2015; 2015:320120. [PMID: 26366309 PMCID: PMC4561092 DOI: 10.1155/2015/320120] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Revised: 07/29/2015] [Accepted: 07/29/2015] [Indexed: 02/05/2023] Open
Abstract
Amyloidosis is a common complication of patients with monoclonal gammopathy of undetermined significance (MGUS), smoldering multiple myeloma (SMM), and multiple myeloma (MM). This proteinaceous material can be deposited intercellularly in any organ system, including the gastrointestinal (GI) tract. In the GI tract, amyloidosis affects the duodenum most commonly, followed by the stomach and colorectum. Gastric amyloidosis causes symptoms of nausea, vomiting, early satiety, abdominal pain, and GI bleeding. A case of upper GI bleeding from gastric amyloidosis is presented in a patient with SMM. Esophagogastroduodenoscopy (EGD) revealed a gastric mass. Endoscopic biopsies revealed amyloid deposition in the lamina propria, consistent with gastric amyloidosis. Liquid chromatography tandem mass spectrometry performed on peptides extracted from Congo red-positive microdissected areas of paraffin-embedded stomach specimens revealed a peptide profile consistent with AL- (lambda-) type amyloidosis. Based on this and multiple other case reports, we recommend that patients with GI bleeding and MGUS, SMM, or MM undergo EGD and pathologic examination of endoscopic biopsies of identified lesions using Congo red stains for amyloidosis for early diagnosis and treatment.
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Affiliation(s)
- Mihajlo Gjeorgjievski
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI 48073, USA
- *Mihajlo Gjeorgjievski:
| | - Treta Purohit
- Division of Gastroenterology & Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, USA
| | - Mitual B. Amin
- Anatomic Pathology, William Beaumont Hospital, Royal Oak, MI 48073, USA
- Oakland University William Beaumont School of Medicine, Royal Oak, MI 48073, USA
| | - Paul J. Kurtin
- Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Mitchell S. Cappell
- Division of Gastroenterology & Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, USA
- Oakland University William Beaumont School of Medicine, Royal Oak, MI 48073, USA
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12
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Small intestinal amyloidosis: a rare cause of diverticular disease. Case Rep Pathol 2014; 2014:362835. [PMID: 25002983 PMCID: PMC4068059 DOI: 10.1155/2014/362835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 05/29/2014] [Indexed: 12/22/2022] Open
Abstract
Systemic amyloidosis frequently involves the small intestine. However, its association with diverticular disease has been seldom reported to date. To draw attention to this rare but potentially harmful association, we herein present an additional case of small bowel diverticular disease associated with amyloidosis.
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13
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Nagano S, Mori M, Kato A, Ono Y, Aoki K, Arima H, Takiuchi Y, Tabata S, Yanagita S, Matsushita A, Ishikawa T, Imai H, Takahashi T. Therapeutic effects of lenalidomide on hemorrhagic intestinal myeloma-associated AL amyloidosis. Intern Med 2013; 52:1101-5. [PMID: 23676598 DOI: 10.2169/internalmedicine.52.8615] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 74-year-old woman with refractory IgG-κ multiple myeloma developed massive melena caused by hemorrhagic submucosal tumors in the duodenum and middle jejunum. A biopsy revealed the tumor to be marked AL amyloid deposition. Treatment with bortezomib did not improve the melena or the underlying disease. The patient also developed multiple amyloidomas in the bilateral femoral heads, which caused a fracture in the left femoral head. Treatment with lenalidomide, as the final therapeutic option, resolved the intractable melena and improved both the intestinal lesions and myeloma. This case shows that successful treatment of multiple myeloma leads to marked improvement of accompanying AL amyloidosis.
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Affiliation(s)
- Seiji Nagano
- Departments of Hematology and Clinical Immunology, Kobe City Medical Center General Hospital, Japan
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14
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Li Y, Liu N, Xu Y, Wang J, Wu L, Zhou Y, Zhu X, Jin X, Chen Q, Zeng X, Zeng X. Widespread purple bulla-like masses of the oral mucosa. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 114:552-7. [DOI: 10.1016/j.oooo.2011.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Revised: 10/30/2011] [Accepted: 11/08/2011] [Indexed: 12/13/2022]
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15
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Lin M, Zhu J, Shen H, Huang J. Gastrointestinal bleeding as an initial manifestation in asymptomatic multiple myeloma: A case report and review of the literature. Oncol Lett 2012; 5:218-220. [PMID: 23255923 DOI: 10.3892/ol.2012.945] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 09/17/2012] [Indexed: 12/17/2022] Open
Abstract
Multiple myeloma (MM) is an uncommon type of malignant hematological neoplasm which, besides primarily involving the bone marrow, has a potent tendency to involve other organs and to present with various clinical manifestations. Involvement of the gastrointestinal (GI) system, particularly presenting with GI hemorrhage, in the course of MM is extremely rare. In the present study, we report a case of a middle-aged male who initially demonstrated GI bleeding and was finally diagnosed with MM. Further laboratory examinations, including analysis of globulin in the blood, bone marrow aspiration and radiogram, supported this diagnosis. This case may promote the possible involvement of plasma cell myeloma in the differential diagnosis of patients with unexplained and refractory GI bleeding. In this study we also present a thorough review of the literature with regard to the association between MM and GI hemorrhage.
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16
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Pavic M, Camus C, Pasquet F, Karkowski L, Galoo E, Nibaud A, Debourdeau P. [Seriousness of AL amyloidosis of the digestive system]. Rev Med Interne 2011; 32:e52-4. [PMID: 21349611 DOI: 10.1016/j.revmed.2009.09.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Revised: 09/15/2009] [Accepted: 09/27/2009] [Indexed: 12/22/2022]
Abstract
Systemic amyloidosis usually does not spare the digestive tract but its involvement is rarely symptomatic. The clinical manifestations are not specific. We report a 64-year-old patient, presenting with a weight loss related to an AL amyloidosis. The amyloidosis was apparently limited to the digestive tract. We discuss the various presentations of the digestive amyloidosis and we insist on the seriousness of this localization.
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Affiliation(s)
- M Pavic
- Service de médecine interne-oncologie, HIA Desgenettes, 108, boulevard Pinel, 69003 Lyon, France.
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17
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Capability of capsule endoscopy in detecting small bowel ulcers. Dig Dis Sci 2009; 54:136-41. [PMID: 18536988 DOI: 10.1007/s10620-008-0320-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2008] [Accepted: 05/06/2008] [Indexed: 12/15/2022]
Abstract
Capsule endoscopy (CE) has proved to be the preferred modality for mucosal pathologies of the small bowel. We evaluated the capability of CE for detecting small bowel ulcers and the contribution of CE in establishing the diagnosis. From a total of 66 patients who had undergone normal upper and lower endoscopy and small bowel follow-through, CE revealed previously undiagnosed ulcer(s) in the small intestines of 22 patients. Final diagnoses of the ulcers of these 22 patients were Crohn's disease (n = 9), Behçet's disease (n = 2), nonspecific jejunoileitis (n = 2), vasculitis (n = 1), gastrointestinal stromal tumor (n = 1), adenocarcinoma (n = 1), lymphoma (n = 1), multiple myeloma (n = 1), Meckel's diverticulum (n = 1) and unknown (n = 3). Capsule endoscopy was extremely useful in establishing the diagnosis. In this study, proximal, distal and diffuse small bowel ulcers were determined at rates of 27.3, 59.0 and 13.7%, respectively. Capsule endoscopy facilitated the detection and assessment of ulcerated mucosal lesions located in the small bowel.
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18
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Lazaraki G, Nakos A, Katodritou E, Pilpilidis I, Tarpagos A, Katsos I. A rare case of multiple myeloma initially presenting with pseudoachalasia. Dis Esophagus 2008; 22:E21-4. [PMID: 19207546 DOI: 10.1111/j.1442-2050.2008.00903.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pseudoachalasia is a rare clinical entity with clinical, radiographic, and manometric features often indistinguishable from achalasia. Primary adenocarcinomas arising at the gastroesophageal junction or a tumor of the distal esophagus are the most frequent causes of pseudoachalasia. Rarely, processes other than esophagogastric cancers including chronic idiopathic intestinal pseudo-obstruction, amyloidosis, sarcoidosis, Chagas' disease, vagotomy, antireflux surgery, pancreatic pseudocysts, von Recklinghausen's neuroinomatosis, gastrointestinal stromal tumor, and other malignancies and rare genetic syndromes, may lead to the development of pseudoachalasia. Secondary achalasia is extremely rare, with less than 100 cases reported in the literature so far. Gastrointestinal manifestations in primary or secondary amyloidosis include abdominal pain, diarrhea, constipation, malabsorption, obstruction, motility disturbance, intestinal infarction, perforation, and hemorrhage; however, gastrointestinal tract involvement is asymptomatic in most instances. We present here a rare case of multiple myeloma initially presenting with dysphagia because of esophageal amyloidosis and manometric findings typical of achalasia.
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Affiliation(s)
- Georgia Lazaraki
- Department of Gastrointestinal Oncology, Theagenion Cancer Hospital, 54248 Thessaloniki, Greece.
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19
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Annaházi A, Németh I, Modok S, Szentpáli K, Tiszlavicz L, Wittmann T, Czakó L. [Amyloidosis induced colonic stricture. The first symptom of myeloma multiplex. A case report]. Orv Hetil 2008; 149:1181-5. [PMID: 18547895 DOI: 10.1556/oh.2008.28365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
UNLABELLED Systemic amyloidosis often involves the gastrointestinal tract and usually presents as ulceration or polypoid lesions. However, annular stricture of the colon due to amyloidosis is very rare. Amyloidosis develops in appr. 10% of multiple myeloma patients with lambda light chain production, it is usually type AL and not a presenting symptom. CASE REPORT A 73-year-old female patient appeared at our hospital with anaemia, abdominal pain and hematochezia. Colonoscopy revealed a circular narrowing of the sigmoid colon suggesting malignancy. The patient underwent sigmoid resection and rectosigmoidal anastomosis was prepared to relieve mechanical obstruction. Surprisingly the histological finding from the resected specimen was amyloidosis. Subcutaneous fat tissue biopsy established the diagnosis of systemic AA amyloidosis. Immunoelectrophoresis revealed an elevated gamma-globulin fraction with IgG lambda monoclonal component, as well as a different lambda light chain. Therefore bone marrow biopsy was carried out which confirmed the diagnosis of multiple myeloma. DISCUSSION Our case is a rare example of the extraordinary tumor-mimicking colon amyloidosis that led to the diagnosis of multiple myeloma. Beside haematological treatment, strict follow-up of the colon process and reconsideration of surgical therapy or endoscopic stenting is of great importance.
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Affiliation(s)
- Anita Annaházi
- Szegedi Tudományegyetem, Altalános Orvostudományi Kar, I. Belgyógyászati Klinika.
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Petre S, Shah IA, Gilani N. Review article: gastrointestinal amyloidosis - clinical features, diagnosis and therapy. Aliment Pharmacol Ther 2008; 27:1006-16. [PMID: 18363891 DOI: 10.1111/j.1365-2036.2008.03682.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Amyloidosis is one of the unusual diseases about which a physician may not think when it is affecting the patient. During the last three decades, there has been an enormous progress in the understanding of the chemical nature, classification, pathogenesis, clinical features, diagnostic measures and therapy of this disorder. AIM To provide an updated review of amyloidosis affecting the gastrointestinal tract. METHODS Review of current medical literature. RESULTS Amyloid proteins (irrespective of the type) can deposit in various parts of the gastrointestinal tract and liver resulting in symptoms of abdominal pain, dysmotility, diarrhoea, gastrointestinal bleeding, hepatomegaly and even portal hypertension with its associated complications. Definitive diagnosis can only be made by histological examination of the affected organ. Disease modifying treatment with high-dose chemotherapy followed by autologous stem-cell transplantation has shown promise. Liver transplantation is an option for a select group of patients. CONCLUSIONS Suspicion of gastrointestinal amyloidosis in patients without known history of amyloidosis is difficult, but should be considered in those older than 30 years with unexplained diarrhoea, weight loss, autonomic dysfunction, malabsorption or proteinuria. While most gastrointestinal complications are managed symptomatically, causal therapy is reserved for a select few from various subtypes of this disorder.
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Affiliation(s)
- S Petre
- Department of Gastroenterology, Carl T. Hayden VA Medical Center, Phoenix, AZ 85012, USA
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21
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Abstract
Amyloidosis is characterized by extracellular deposition of abnormal protein. There are six types: primary, secondary, hemodialysis-related, hereditary, senile, and localized. Primary (AL) amyloidosis is associated with monoclonal light chains in serum and/or urine with 15% of patients having multiple myeloma. Secondary (AA) amyloidosis is associated with inflammatory, infectious, and neoplastic diseases. The presentation is protean, including macroglossia, a dilated and atonic esophagus, gastric polyps or enlarged folds, and luminal narrowing or ulceration of the colon. Amyloid deposition in the gastrointestinal (GI) tract is greatest in the small intestine. The symptoms include diarrhea, steatorrhea, or constipation. Pseudo-obstruction carries a particularly grave prognosis, often not responding to pro-motility agents. Hepatic involvement is common, but the clinical manifestations are usually mild with hepatomegaly and an elevated alkaline phosphatase level. Biopsies to diagnose amyloidosis can be taken from the fat, kidney, intestine, or bone marrow. The safety of liver biopsies is controversial. With Congo Red stain, amyloid appears red in normal light and apple-green in polarized light. Treatment for AL amyloidosis is chemotherapy and stem cell transplantation; treatment for AA amyloidosis is control of the underlying disease. Amyloidosis should be considered in patients with proteinuria, cardiomyopathy, hepatomegaly (with mildly abnormal liver tests), peripheral and autonomic neuropathy, weight loss, and GI symptoms.
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Affiliation(s)
- Ellen C Ebert
- Department of Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey 09803, USA
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22
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López L, González K, Navarrete G, Novales J, Guarneros A, Cortés B, Téllez G. Multiple myeloma and systemic amyloidosis. Int J Dermatol 2008; 47:165-7. [DOI: 10.1111/j.1365-4632.2008.03352.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Müller AMS, Geibel A, Neumann HPH, Kühnemund A, Schmitt-Gräff A, Böhm J, Engelhardt M. Primary (AL) Amyloidosis in Plasma Cell Disorders. Oncologist 2006; 11:824-30. [PMID: 16880241 DOI: 10.1634/theoncologist.11-7-824] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Primary (AL) amyloidosis is the most common form of systemic amyloidosis. The morbidity arises from extracellular deposition of immunoglobulin light chain (LC) fibrils in major organs, such as the kidneys, heart, and bowel. Organ dysfunction contributes to a high mortality and poor prognosis, with a median survival time of 1-2 years from diagnosis. Here, we present a 46-year-old man with an exceptional clinical course of an LC multiple myeloma with generalized amyloidosis, causing renal insufficiency, congestive heart failure, and complete intestinal necrosis. We have summarized recent knowledge on AL amyloidosis, its association with monoclonal gammopathies, clinical presentations, diagnostic tools, and treatment strategies. Our comprehensive overview of this rare and often fatal disease aims to increase the awareness of AL amyloidosis. This may facilitate earlier diagnosis, and thus allow initiation of prompt and specific therapies, which are indispensable in order to improve disease prognosis.
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Affiliation(s)
- Antonia M S Müller
- Department of Hematology/Oncology, University Medical Center Freiburg, Hugstetterstr. 55, D-79106 Freiburg, Germany
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Kazama T, Ng CS, Giralt SA. Multiphasic CT and MRI appearances of extramedullary multiple myeloma involving the stomach, pancreas, and bladder. Clin Imaging 2005; 29:263-5. [PMID: 15967318 DOI: 10.1016/j.clinimag.2004.11.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2004] [Revised: 09/30/2004] [Accepted: 11/02/2004] [Indexed: 12/22/2022]
Abstract
Multiple myeloma is a hematological malignancy characterized by the uncontrolled proliferation of clonal plasma cells. Skeletal involvement is one of its hallmarks, while extraosseous involvement is comparatively uncommon. There have been no previous reports of the imaging findings of multiple myeloma involving the stomach, pancreas, and bladder in the same patient. The stomach and pancreatic lesions were demonstrated as hypervascular nodules on computed tomography (CT), more conspicuous on arterial phase images. Early phase post-contrast imaging might improve the detection of extraosseous myeloma.
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Affiliation(s)
- Toshiki Kazama
- Department of Diagnostic Radiology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030-4009, USA
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25
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Iijima-Dohi N, Shinji A, Shimizu T, Ishikawa SZ, Mukawa K, Nakamura T, Maruyama K, Hoshii Y, Ikeda SI. Recurrent gastric hemorrhaging with large submucosal hematomas in a patient with primary AL systemic amyloidosis: endoscopic and histopathological findings. Intern Med 2004; 43:468-72. [PMID: 15283181 DOI: 10.2169/internalmedicine.43.468] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 64-year-old woman who suffered intractable gastric ulcers with hemorrhaging showed huge submucosal hematomas in her stomach on the endoscopic examination. Since gastric mucosal biopsy revealed amyloid deposition and IgG lambda type M protein was detectable in her serum, she was diagnosed as having primary AL systemic amyloidosis. The gastric hemorrhages did not improve despite intensive medication, so total gastrectomy was performed, resulting in an unfavorable outcome. Massive deposition of amyloid with A lambda immunoreactivity was seen on the submucosal vessels in her stomach. This is a rare primary AL systemic amyloidosis case showing recurrent and fatal gastric submucosal hematomas.
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Chang HS, Myung SJ, Yang SK, Jung HY, Lee GH, Hong WS, Kim JH, Min YI, Kim HC, Ha HK, Kim JS. Massive small bowel bleeding in a patient with amyloidosis. Gastrointest Endosc 2004; 59:126-9. [PMID: 14722567 DOI: 10.1016/s0016-5107(03)02352-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Hye-Sook Chang
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Poullos PD, Stollman N. Gastrointestinal Amyloidosis: Approach to Treatment. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2003; 6:17-25. [PMID: 12521568 DOI: 10.1007/s11938-003-0029-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The main treatment goals in amyloidosis are twofold: 1) to diagnose the underlying disease state accurately to guide effective primary therapy (if available) and 2) to ameliorate symptoms. The correct diagnosis is essential because disease-modifying therapies vary widely according to the underlying primary pathology. Primary treatment options remain limited. The best evidence is for high-dose chemotherapy, followed by autologous stem cell transplantation in patients with primary systemic amyloidosis. High-flux hemodialysis (HD) may prevent HD-related amyloidosis. Liver transplantation may be an option for patients with familial amyloidotic polyneuropathy. Several novel specific therapies are under investigation, including small molecule drugs and vaccines. Their efficacy and safety in humans remain to be demonstrated. In the absence of specific cures, symptom-directed therapy assumes a paramount role and can improve quality of life by mitigating diarrhea or pain, for example.
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Affiliation(s)
- Peter D. Poullos
- San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, GI Suite 3-D, San Francisco, CA 94110, USA
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Abstract
Mr. F received several different treatment regimens for MM. He required a cardioprotectant, dexrazoxane, to continue treatment with the VAD regimen. He received interferon, high-dose chemotherapy with tandem stem cell transplants, and newer agents used in the treatment of MM, such as thalidomide and topotecan. However, as illustrated by Mr. F's case study, MM remains an incurable disease despite advances in its treatment.
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Affiliation(s)
- Barbara Felder
- Outpatient Clinic, University of Pennsylvania Cancer Center, Philadelphia, USA.
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