Systemic capillary leak syndrome with monoclonal IgG and complement alterations. A case report on an episodic syndrome

Tranexamic acid: Beyond antifibrinolysis

Tranexamic acid (TXA) is a popular antifibrinolytic drug widely used in hemorrhagic trauma patients and cardiovascular, orthopedic, and gynecological surgical patients. TXA binds plasminogen and prevents its maturation to the fibrinolytic enzyme plasmin. A number of studies have demonstrated the broad life-saving effects of TXA in trauma, superior to those of other antifibrinolytic agents. Besides preventing fibrinolysis and blood loss, TXA has been reported to suppress posttraumatic inflammation and edema. Although the efficiency of TXA transcends simple inhibition of fibrinolysis, little is known about its mechanisms of action besides the suppression of plasmin maturation. Understanding the broader effects of TXA at the cell, organ, and organism levels are required to elucidate its potential mechanisms of action transcending antifibrinolytic activity. In this article, we provide a brief review of the current clinical use of TXA and then focus on the effects of TXA beyond antifibrinolytics such as its anti-inflammatory activity, protection of the endothelial and epithelial monolayers, stimulation of mitochondrial respiration, and suppression of melanogenesis.

Systemic Capillary Leak Syndrome, Leukotrienes, and Anaphylaxis

The association of cysteinyl leukotrienes with plasma exudation allowed the authors to form the hypothesis that rates of leukotriene excretion would be increased in the acute phase of systemic capillary leak syndrome (SCLS) and that leukotriene-modifier therapy would reduce the frequency and severity of life-threatening episodes. The authors report the association of SCLS in 3 cases, 1 with seafood-induced anaphylaxis. Rates of urinary leukotriene excretion were greater during the evolution of an episode than after resolution. In a third case, the rate of urinary leukotriene excretion was significantly higher when symptoms were evolving than when they were absent (230 ± 17 vs 110 ± 6 pg/mg, P < 0.001). Treatment with a leukotriene receptor (cys-LT1) antagonist eliminated episodes in 1 patient. Treatment with the 5-lipoxygenase inhibitor zileuton was completely effective in another patient and prevented life-threatening episodes in the patient with SCLS after seafood exposure. The authors' finding that allergen exposure—associated episodes of SCLS were eliminated by allergen avoidance implies that anaphylaxis can present as SCLS. The acute phase of all 3 forms of SCLS (paraprotein associated, anaphylaxis associated, and idiopathic) is associated with increased excretion of cystinyl leukotrienes, and leukotriene-modifier treatment appears to control the disease.

Idiopathic systemic capillary leak syndrome (Clarkson's disease): the Mayo clinic experience

OBJECTIVE

To determine clinical features, natural history, and outcome of a well-defined cohort of 25 consecutive patients with idiopathic systemic capillary leak syndrome (SCLS) evaluated at a tertiary care center.

PATIENTS AND METHODS

Records of patients diagnosed as having SCLS from November 1, 1981, through April 30, 2008, were reviewed. Descriptive statistics were used to analyze patient demographics, clinical features, complications, and therapeutic interventions.

RESULTS

Of the 34 patients whose records were reviewed, 25 fulfilled all diagnostic criteria for SCLS. The median age at diagnosis of SCLS was 44 years. Median follow-up of surviving patients was 4.9 years, and median time to diagnosis from symptom onset was 1.1 years (interquartile range, 0.5-4.1 years). Flulike illness or myalgia was reported by 14 patients (56%) at onset of an acute attack of SCLS, and rhabdomyolysis developed in 9 patients (36%). Patients with a greater decrease in albumin level had a higher likelihood of developing rhabdomyolysis (p=.03). Monoclonal gammopathy, predominantly of the IgG-κ type, was found in 19 patients (76%). The progression rate to multiple myeloma was 0.7% per person-year of follow-up. The overall response rate to the different therapies was 76%, and 24% of patients sustained durable (>2 years) complete remission. The estimated 5-year overall survival rate was 76% (95% confidence interval, 59%-97%).

CONCLUSION

Systemic capillary leak syndrome, a rare disease that occurs in those of middle age, is usually diagnosed after a considerable delay from onset of symptoms. The degree of albumin decrement during an attack correlates with development of rhabdomyolysis. A reduction in the frequency and/or the severity of attacks was seen in nearly three-fourths of patients who were offered empirical therapies. The rate of progression to multiple myeloma appears to be comparable to that of monoclonal gammopathy of undetermined significance.

[Idiopathic capillary leak syndrome]

Idiopathic capillary leak syndrome (ICLS) is a rare and poorly known condition. Since the first description in 1960, about hundred cases have been reported. A French register that was initiated in 1997 provides a better knowledge of the natural course of the disease and highlights some therapeutic issues. ICLS mainly affects middle-aged adults. The prognosis is poor with a 10-year mortality rate around 34%. Severe crisis and complications occurring in intensive care units account for 80% of the mortality. Diagnosis relies on an almost pathognomonic association: recurrent attacks of hypotension and hemoconcentration with paradoxical hypoalbuminemia. A monoclonal gammopathy is found in about 80% of patients. Physiopathology still remains unclear. Paraprotein toxicity has never been demonstrated. As a result, no evidence-based treatment is available neither for acute crisis nor for prophylaxis. Management of acute episodes is mainly symptomatic. Fluid infusion must be cautious because it can induce complications during the recovery phase. Patient education is a major measure to prevent recurrent attacks. Beta-2 stimulants were reported to reduce the frequency and severity of episodes and were considered as the recommended prophylactic measure. However, early data from the French register suggest that intravenous immunoglobulins are more effective in reducing both frequency and severity of the attacks. Inclusion of patients with ICLS in a register is crucial to improve the knowledge about aetiology and treatment of this disorder.

Systemic capillary leak syndrome resulting in compartment syndrome and the requirement for a surgical airway

We report on a case of systemic capillary leak syndrome associated with a monoclonal band on plasma electrophoresis. In our patient hospital admission was precipitated by ischaemic pain in the left lower limb, associated with polycythaemia, renal failure and hypovolaemic shock. Fluid resuscitation, venesection and renal replacement therapy were instituted but a compartment syndrome developed necessitating surgery. Failure of tracheal intubation resulted in the requirement for a surgical airway. Despite surgical and resuscitative efforts the outcome was fatal from hypovolaemia and hyperkalaemia. We aim to highlight the difficulties in managing this condition and to remind healthcare workers to include it in the differential diagnoses for patients presenting with polycythaemia; in particular polycythaemic patients with a monoclonal band on plasma electrophoresis.

Ultrastructure of the microvessels in skeletal muscle in a case of systemic capillary leak syndrome

The microvessels of skeletal muscle were examined electron microscopically in a case of systemic capillary leak syndrome (SCLS). One biopsy was taken in a free interval of the disease and one about 6 hours after the onset of an attack with hypovolemia. The microvascular endothelium exhibited a large number of multivesicular bodies, especially in the specimen obtained during an attack. Possibly this indicates a high heterophagic activity of the endothelium. A blebbing of the luminal surface of arteriolar endothelium was observed in the attack specimen. Since a complement activation seemed to occur during attacks, the blebbing is tentatively interpreted as a sign of a complement-mediated injury to the endothelium, leading to a breakdown of the endothelial barrier. This mechanism might explain the dramatic increase of microvascular permeability to plasma proteins during an attack of SCLS. The findings did not indicate that the increase might depend on some disturbance of the transendothelial vesicular transport function, nor could any openings of endothelial junctions, as in inflammation, be demonstrated. Regionally the periendothelial basal lamina appeared thickened, a finding which seems common in angiopathies of different kinds.

High-dose intravenous immunoglobulins dramatically reverse systemic capillary leak syndrome

OBJECTIVE

The objective of this study was to report the dramatic improvement of patients with systemic capillary leak syndrome obtained with high-dose intravenous immunoglobulins.

DESIGN

Systemic capillary leak syndrome is a rare and life-threatening disorder characterized by hypotension that can lead to shock, weight gain, hypoalbuminemia, and elevated hematocrit secondary to unexplained episodic capillary fluid extravasation into the interstitial space. Because its cause is unknown, systemic capillary leak syndrome treatment has remained largely supportive.

MAIN RESULTS

Intravenous immunoglobulins administration to a patient with refractory systemic capillary leak syndrome yielded dramatic improvement. The patient is still alive 11 yrs after systemic capillary leak syndrome diagnosis and receives intravenous immunoglobulins monthly. Later, based on that result, intravenous immunoglobulins were successfully given to two other patients during the acute phase of systemic capillary leak syndrome. Both are still alive 8 and 1.5 yrs after receiving intravenous immunoglobulins at the onset of each flare.

CONCLUSIONS

Intravenous immunoglobulins were effective against systemic capillary leak syndrome symptoms in three patients, but their exact mechanism remains unknown. Their immunomodulatory effect merits further investigation.

Systemisches Kapillarlecksyndrom als Ursache eines Kompartmentsyndroms beider Unterschenkel und eines Unterarms

Systemic capillary leak syndrome is a rare disorder which causes recurrent episodes of hypovolemic shock due to a markedly increased plasma shift into the interstitium. Hemoconcentration, hypoalbuminemia and a monoclonal gammopathy are characteristic laboratory findings. A rare manifestation of this disease is a compartment syndrome with rhabdomyolysis and acute renal failure. We describe a patient who suffers from a compartment syndrome of both lower legs and the left forearm secondary to systemic capillary leak syndrome, and discuss the pathophysiological background.

Administration of Aerosolized Terbutaline and Budesonide Reduces Chlorine Gas–Induced Acute Lung Injury

BACKGROUND

The pathophysiology and treatment of chlorine gas-induced acute lung injury is poorly characterized and based on anecdotal data. This study aimed to assess the effects of aerosolized beta-2 adrenergic agonist and corticosteroid therapy on chlorine gas-induced lung injury.

METHODS

Anesthetized, ventilated pigs were exposed to chlorine gas (400 parts per million for 20 minutes), then assigned randomly 30 minutes later to receive aerosolized terbutaline, budesonide, terbutaline followed by budesonide or placebo (6 pigs in each group). Hemodynamics, gas exchange, and lung mechanics were evaluated for another 5 hours.

RESULTS

All the animals demonstrated an immediate increase in airway and pulmonary artery pressure as well as sharp drops in arterial oxygen tension (PaO2) and lung compliance (CL). Recovery of PaO2 and CL was greatest in the terbutaline plus budesonide group, but therapy with terbutaline and budesonide alone also was associated with significant improvement in PaO2 and CL, as compared with placebo.

CONCLUSIONS

Treatment of acute chlorine gas lung injury with aerosolized terbutaline followed by aerosolized budesonide improved lung function. Combined treatment was more effective than treatment with either drug alone.

Monoclonal gammopathies of undetermined significance: a review

Monoclonal gammopathy of undetermined significance (MGUS) denotes the presence of a monoclonal protein (M-protein) in patients without evidence of multiple myeloma (MM), macroglobulinemia, amyloidosis (AL), or a related plasma cell proliferative disorder. MGUS is found in approximately 3% of persons older than 70 years and in about 1% of those older than 50 years. In a series of 1384 patients from south-eastern Minnesota in whom MGUS was diagnosed at Mayo Clinic from 1960 through 1994, the risk of progression was 1% per year. Patients were at risk of progression even after 25 years or more of a stable monoclonal gammopathy. The risk of development of MM was increased by 25-fold, the risk of macroglobulinemia was 46-fold, and the risk of primary AL was 8.4-fold when compared with a similar population (Surveillance, Epidemiology and End Results). The concentration of the serum M-protein was the major independent predictor of progression. Patients with an immunoglobulin M (IgM) or an IgA monoclonal gammopathy had a higher risk of progression than those with an IgG monoclonal gammopathy. The presence of a urine M-protein or the reduction of one or more uninvolved Igs was not a risk factor for progression. MGUS may be associated with many different disorders, including lymphoproliferative diseases, leukemia, connective tissue disorders, dermatologic diseases, and neurologic disorders.

Monoclonal gammopathies of undetermined significance

The term 'monoclonal gammopathy of undetermined significance' denotes the presence of a monoclonal protein in patients without evidence of multiple myeloma, macroglobulinemia, amyloidosis or related plasma cell proliferative disorders. The disorder has been found in approximately 3% of persons older than 70 years and in approximately 1% of persons older than 50 years. A population-based study included 1384 patients from south-eastern Minnesota who had the disorder diagnosed at the Mayo Clinic from 1960 through 1994. Risk of progression was about 1% per year, but patients were at risk of progression even after 25 years or more of stable monoclonal gammopathy of undetermined significance. The risk for development of multiple myeloma was increased 25-fold; the risk of macroglobulinemia, 46-fold; and the risk of primary amyloidosis, 8.4-fold. Concentration and type of monoclonal protein were the only independent predictors of progression. The presence of a urine monoclonal protein and the reduction of one or more uninvolved immunoglobulins were not risk factors for progression. Monoclonal gammopathy of undetermined significance may be associated with various disorders, including lymphoproliferative diseases, leukemia, von Willebrand disease, connective tissue diseases and neurologic disorders.

Initial evidence of endothelial cell apoptosis as a mechanism of systemic capillary leak syndrome

BACKGROUND

Systemic capillary leak syndrome (SCLS) is a rare disorder of unknown etiology that is characterized by acute recurrent attacks of hypovolemic shock commonly following an inflammatory stimulus such as a viral illness. Prophylactic therapy is generally ineffective, and the outcome is frequently fatal.

METHODS

In order to investigate the cellular mechanisms leading to SCLS, we examined the effects of sera from two patients with active SCLS on microvascular endothelial cell apoptosis in vitro. Apoptosis was determined by morphologic criteria, DNA fragmentation, annexin V stain, and by a quantitative photometric assay. The apoptotic pathway was investigated by Western blot of endothelial cells lysate after exposure to SCLS sera.

RESULTS

The sera from patients with active SCLS mediated profound apoptosis of microvascular endothelial cells shortly after exposure. The exposed microvascular endothelial cells underwent immediate apoptosis as evidenced by morphologic changes, plasma membrane phosphatidylserine exposure, and by DNA fragmentation. Increased Bax/Bcl-2 ratio in endothelial cells exposed to SCLS sera was observed and suggested an oxidation injury as the possible mechanism for endothelial apoptosis. This potential mechanism was further explored by measuring intracellular reactive oxygen species (ROS) following SCLS serum exposure. Sera from both patients caused marked increases in ROS, initially detectable at 1 h and persisted for at least 12 h, with control serum from healthy subjects showing no effect on basal endothelial cell ROS concentrations.

CONCLUSION

Components from the sera of patients with active systemic capillary leak syndrome in contrast to healthy subject sera mediate early and extensive endothelial apoptosis in vitro that is associated with oxidation injury. These data represent compelling initial evidence for oxidation-induced apoptosis as a likely mechanism for endothelial injury leading to SCLS.

Noncardiogenic pulmonary edema: an unusual and serious complication of anticancer therapy

Noncardiogenic pulmonary edema (NCPE) is a rare and less well-recognizable pulmonotoxic syndrome of anticancer therapy than pneumonitis/fibrosis. NCPE is a clinical syndrome characterized by simultaneous presence of severe hypoxemia, bilateral alveolar infiltrates on chest radiograph, and no evidence of left atrial hypertension/congestive heart failure. The diagnosis of drug-related NCPE relies upon documented exclusion of any infectious, metabolic, or cancer-related causes. The time proximity to therapy with drugs that are known to precipitate NCPE, any preceding episodes of flu-like symptoms during previous chemotherapy courses and possible response to corticosteroids may further support such a diagnosis. Cancer therapeutic agents clearly associated with NCPE are cytarabine, gemcitabine, and interleukin-2, as well as all-trans retinoic acid in acute promyelocytic leukemia patients, while a few other compounds have rarely or occasionally been implicated. The pathophysiology of lung injury in drug-induced NCPE remains unclear. There are indications suggesting that both a direct cytotoxic insult to the lung epithelial cells and induction of a cytokine-triggered inflammatory response may be involved in its pathogenesis. By distinction to drug-induced pulmonary pneumonitis that may lead to permanent pulmonary fibrosis, NCPE if not fatal, can be reversed upon prompt recognition, following immediate discontinuation of the offensive drug and start of intensive supportive treatment and intravenous corticosteroids.

Chronic systemic capillary leak syndrome. Report of a case and review of the literature

Systemic capillary leak syndrome (SCLS) is a rare condition characterized by recurrent episodes of generalized oedema and severe hypotension, associated with paraproteinaemia. In addition to the acute form, a few cases of chronic SCLS have been reported. We describe a 64-year-old woman who was hospitalized because of a 6-month history of progressive generalized oedema with pericardial and pleural effusions, associated with a serum paraprotein. Clinical and laboratory findings were consistent with a chronic form of SCLS. Treatment with prednisone, furosemide and theophylline was started, which led to a gradual improvement in 2 weeks and a persistent remission after 9 months. This report indicates that SCLS may occur in a chronic form, which seems to be responsive to a therapeutic regimen with prednisone, furosemide, and theophylline.

Pulmonary infections associated with systemic capillary leak syndrome attacks in a patient with hypogammaglobulinemia

Systemic capillary leak syndrome (SCLS) is a rare disorder of unknown etiology, characterized by recurrent hypovolemic shock attacks associated in most cases with a serum monoclonal immunoglobulin. Prophylactic therapy is usually disappointing and the outcome is often fatal. We report on a patient with recurrent hypovolemic shocks consistent with the diagnosis of SCLS associated with severe serum panhypogammaglobulinemia but no detectable monoclonal immunoglobulin or B cell proliferation. Attacks were often preceded by severe respiratory infections. Both infections and attacks were successfully prevented by i.v. gammaglobulin replacement. Further evaluation is needed to assess the efficacy of i.v. gammaglobulins in patients with SCLS but without hypogammaglobulinemia.

Systemic capillary leak syndrome: report on 13 patients with special focus on course and treatment

BACKGROUND

Systemic capillary leak syndrome (SCLS) is a rare condition characterized by unexplained episodic capillary hyperpermeability due to a shift of fluid and protein from the intravascular to the interstitial space. This results in diffuse swelling, weight gain, and renal shut-down. From the first publication in 1960, only 34 cases have been reported.

OBJECTIVE

To collate enough patients to observe the natural history of the disease and evaluate the efficacy of empiric treatments.

DESIGN

Multicentric retrospective study.

RESULTS

Thirteen patients (6 women and 7 men) were collated with a mean follow-up of 6.4 years. Eight patients are still alive after a mean of 5.6 years (range 1 to 15). Three patients out of the 11 who were not lost to follow-up died; 1 during an attack and 2 because of a progression towards multiple myeloma.

CONCLUSIONS

Our series shows an improvement in the prognosis of SCLS due most likely to improved management during attacks. Some patients' disease could evolve into a multiple myeloma. Treatment is still empiric and no prophylactic therapy, including terbutaline associated with aminophylline, has clearly proven its efficacy.

Monoclonal gammopathy of undetermined significance (MGUS)

MGUS is characterized by a serum M-protein concentration of less than 30 milligrams (3 g/dl), fewer than 10% plasma cells in the bone marrow, no or only small amounts of M-protein (Bence Jones protein) in the urine, the absence of lytic lesions, anaemia, hypercalcaemia and renal insufficiency, and most importantly, stability of the M-protein and failure of the development of additional abnormalities. Electrophoresis on agarose, followed by immunoelectrophoresis or immunofixation for the identification of the type of M-protein, is recommended. In 1994, 971 patients at the Mayo Clinic were found with a serum M-protein. The most frequent diagnosis was MGUS, which occurred in 52% of patients. MGUS is found in approximately 3% of people older than 70 years and in at least 1% of those aged over 50. The incidence of monoclonal gammopathies increases with advancing age and is higher in African-Americans than in Caucasians. Two hundred and forty-one patients from the Mayo Clinic with a monoclonal gammopathy but no evidence of MM, macroglobulinaemia, amyloidosis, lymphoma or related disorders were followed for 24-38 years. In 62 patients (26%), multiple myeloma, macroglobulinaemia, amyloidosis or a malignant lymphoproliferative disorder developed (the actuarial rate of development of serious disease at 10 years was 16%; at 20 years, 33%; and at 25 years, 40%). Thirty patients (12%) were alive and had a stable M-protein value. In 23 patients (10%), the serum M-protein level increased to 30 milligrams (3 g/dl) or more, but they did not require therapy for myeloma or related disorders. Fifty-two per cent of patients (126) died of unrelated diseases without the development of a malignant plasma cell lymphoproliferative disorder. The actual rate of development of serious disease was the same for those with IgG, IgA and IgM M-proteins. Differentiation of MGUS from myeloma or macroglobulinaemia is difficult. The M-protein value must be measured periodically and clinical evaluation carried out to determine whether or not serious disease has developed.

Systemic capillary leak syndrome in a child

A child with idiopathic systemic capillary leak syndrome had four episodes between 3 and 3 years 9 months of age, all characterized by the sudden onset of hypovolemic shock without any obvious triggering factor. Between the attacks she is well and free of symptoms. Early establishment of intravenous access facilitates volume replacement during the acute episodes.

Systemic capillary leak syndrome

Systemic capillary leak syndrome is a rare, severe disorder with a high mortality rate. It consists of the shift of fluid and proteins from the intravascular to the extravascular compartment with subsequent hypovolemic shock. We describe a 34-year-old-woman who had several episodes of generalized edema that evolved to hypovolemic shock. During the acute phase, laboratory investigations revealed marked hypoproteinemia, leukocytosis, and high levels of hematocrit and hemoglobin. A paraprotein IgG kappa chain was detected. Although different therapeutic trials were used, the patient continued to have similar episodes and she died during an acute episode 2 1/2 years after the first symptom of this disorder. The cause of systemic capillary leak syndrome is unknown. The presence of a paraprotein IgG is frequent in this group of patients.

Idiopathic capillary leak syndrome complicated by massive rhabdomyolysis

Idiopathic systemic capillary leak syndrome (Clarkson's disease) is characterized by recurring attacks of increased capillary permeability, resulting in severe hypovolemic shock due to plasma extravasation. Additional laboratory features include association with a monoclonal gammopathy, extreme hemoconcentration, and hypoalbuminemia. Rare manifestations of this syndrome are renal damage and rhabdomyolysis due to increased compartment pressure and ischemic myonecrosis. We present the findings in two patients with capillary leak syndrome complicated by severe rhabdomyolysis, in one case leading to acute renal failure. We review therapeutic aspects of this rare syndrome and emphasize the importance of early diagnosis and of prompt and aggressive fluid replacement.

Control of systemic capillary leak syndrome with aminophylline and terbutaline

PURPOSE

Patients with systemic capillary leak syndrome have a characteristic triad of hypotension, hemoconcentration, and monoclonal gammopathy. They have frequent and severe attacks of hemoconcentration and hypotension accompanied by marked plasma shifts. The exact role of this monoclonal protein is unknown, but it probably leads, in some way, to an increase in capillary permeability. Despite efforts to resuscitate the patients during an acute attack, the syndrome is often fatal. Some success has been obtained in preventing the attacks with the beta-adrenergic-stimulating agent terbutaline. The purpose of this study was to determine the effectiveness of aminophylline and terbutaline in the treatment of systemic capillary leak syndrome.

METHODS

Over a decade, three patients with systemic capillary leak syndrome presented at our institution. All three patients were treated with terbutaline and aminophylline. Prednisone was used during the course of treatment in each of the three patients.

RESULTS

In contrast to previous reports of partial or temporary control of episodes, all three patients are alive with almost complete resolution of their recurrent attacks and have been able to return to their normal lifestyles.

CONCLUSION

The regimen of terbutaline and aminophylline effectively prevents the attacks of hypotension and hemoconcentration that occur in systemic capillary leak syndrome. The role of prednisone is not clear. Until more is known about the pathophysiology of the disorder, treatment must remain empiric and supportive.

Pulmonary oedema with shock induced by hydrochlorothiazide: a rare side effect mimicking myocardial infarction

The case of a 68 year old man in whom hydrochlorothiazide induced pulmonary oedema with hypovolaemic shock is presented. The condition was misdiagnosed as myocardial infarction until an early echocardiogram excluded a cardiac cause. The diagnosis was confirmed by an oral challenge.

Plasma cell dyscrasias: current status

This is a review of the current status of the monoclonal gammopathies (plasma cell dyscrasias). We begin with the recognition of a monoclonal protein in serum and urine. We briefly discuss the differential diagnosis of the monoclonal gammopathies. Clinical and laboratory findings as well as the management of multiple myeloma are addressed. Future approaches for the treatment of myeloma are provided. The variant forms of multiple myeloma, including smoldering myeloma, plasma cell leukemia, nonsecretory myeloma, IgD myeloma, osteosclerotic myeloma, solitary plasmacytoma of bone, and extramedullary plasmacytoma, are briefly reviewed. Diagnosis and treatment of Waldenström's macroglobulinemia are presented. The recognition and differential diagnosis of the heavy-chain diseases (gamma, alpha, and mu) are included. Monoclonal gammopathy of undetermined significance ("benign" monoclonal gammopathy) is presented in detail. Amyloidosis is not included in this review.

Monoclonal gammopathy and multiple myeloma in the elderly

The term 'benign monoclonal gammopathy' indicates the presence of a monoclonal protein in persons without evidence of multiple myeloma, macroglobulinaemia, amyloidosis, lymphoproliferative disease, or other related disorders. The term 'monoclonal gammopathy of undetermined significance' (MGUS) is preferable because it is not known at diagnosis whether an M-protein will remain stable and benign or develop into symptomatic multiple myeloma or related disorders. Immunoelectrophoresis and immunofixation of the serum and urine are necessary to determine the presence and type of M-protein. At the Mayo Clinic, follow-up data have been gathered for more than 13 years on 241 patients with an initial benign monoclonal gammopathy. Nineteen per cent of these patients developed multiple myeloma, macroglobulinaemia, amyloidosis, or related diseases during the follow-up period. There is no reliable technique for differentiating a patient with a benign monoclonal gammopathy from one who will subsequently develop a serious disease. It is necessary to follow these patients indefinitely. Important in the complete understanding of the elderly patient with monoclonal gammopathy are the following: clinical manifestations, laboratory findings, and differential diagnosis of multiple myeloma; the course and prognosis and the induction therapy and treatment of multiple myeloma; newer therapeutic approaches; and the management of complications such as hypercalcaemia, hyperuricaemia, renal failure, bacterial infections, skeletal disease, and neurological problems.

[Hypovolemic shock caused by an increase in capillary permeability after cesarean section]

A 24 year old woman was delivered by caesarean section after an uncomplicated full-term pregnancy. Non-specific prodromes appeared 48 h later, with development of a severe shock. After confirmation of hypovolaemia, attention was focused on the abnormal haematological findings (a sharp drop in serum proteins with a rise in haematocrit) which suggested major leakage of plasma. Treatment based on infusions of plasma and albumin failed, and the patient died in a state of anasarca and pulmonary oedema with normal wedge pressure. 18 similar cases have already been published, six of which were in obstetric or surgical patients. After analysing the prodromes and its onset, its pathophysiological mechanisms and treatment are discussed.