Improvement of scleredema associated with IgA multiple myeloma after chemotherapy

Scleredema in the Setting of Monoclonal Gammopathy of Unknown Significance With Progression to Multiple Myeloma: A Case Report

Type 2 scleredema on the background of monoclonal gammopathy of undetermined significance (MGUS) is a rare and progressive connective tissue disorder with very few cases reported to date. It is characterized by chronic and diffuse induration of the skin that begins in the upper back and neck and progresses proximally to distally, involving the shoulders, trunk, and arms; the hands are usually spared. Here, we present an unusual case of long-standing scleredema that progressed to involve the hands and fingers. This case was further complicated by new-onset Raynaud's phenomenon, splenomegaly, lymphadenopathy, the development of a plasmacytoma, and eventual progression to multiple myeloma. We highlight the differential diagnoses for his complex presentation, the workup that was completed, and current treatment options.

Scleredema associated with immunoglobulin A-κ smoldering myeloma: a case report and review of the literature

Background

Scleredema is a rare sclerodermoid skin condition characterized by diffuse symmetrical thickening of the upper part of the body. Its association with monoclonal gammopathy and myeloma was recently described; very few cases have been reported to date.

Case presentation

A 66-year-old Sri Lankan woman who had been followed in a dermatology unit for 34 years with diffuse systemic sclerosis presented with an acute exacerbation of the skin disease. Absence of Raynaud’s phenomenon; sclerodactyly; characteristic lung, gastrointestinal, and cardiac involvement of systemic sclerosis; and repeatedly negative antinuclear antibodies test results led to reevaluation for the possibility of scleredema. Skin biopsies from four body sites showed normal epidermis and thickened reticular dermis with swollen collagen bundles separated from one another by clear spaces, resulting in fenestration. The skin appendages were not atrophied or bound down. Alcian blue staining showed interstitial mucin deposition. Serum protein electrophoresis demonstrated an abnormal monoclonal band in the β-region with a paraprotein level of 8.9 g/dl. Immunofixation showed an abnormal band in the γ-region consisting of immunoglobulin A and κ. Bone marrow biopsy revealed abnormal monoclonal plasma cells (15%) with multinuclearity. There was no evidence of end organ damage, and whole-body magnetic resonance imaging did not reveal any evidence of bone involvement. The patient’s diagnosis was revised as scleredema type 2 associated with IgA-κ, and she was referred to a hemato-oncologist for chemotherapy, which led to significant improvement in the skin condition.

Conclusions

Scleredema is a rare disorder that has an enigmatic, rare association with monoclonal gammopathy. Dermatologists should be aware of this rare but important association.

An Unusual Presentation of a Rare Scleroderma Mimic: What is Behind the Scenes?

BACKGROUND

Scleroderma or systemic sclerosis (SSc) is a rare systemic autoimmune disease. Many conditions mimic the presentation of SSc, especially skin thickening and fibrosis. One of these conditions is scleredema, a rare collagen and mucin deposition disorder which was found to be associated with diabetes mellitus, streptococcal infection or monoclonal gammopathy.

CASE PRESENTATION

A 55 years old female presented with insidious onset and progressive course of diffuse skin thickening of face, neck, arms, forearms, thighs, chest, back, and excluding both hands and feet of 6 years' duration associated with arthralgia, dysphagia and dyspnea on exertion of 1- year duration. There was no history of Raynaud's phenomenon. Erythrocyte sedimentation rate was 100 mm/1st h, autoantibodies for SSc were negative, nail fold capillaroscopy normal, pulmonary function tests showed restrictive pattern and high-resolution computed tomography showed interstitial lung fibrosis. Patient was not fulfilling the American collage of rheumatology/European League Against Rheumatism classification criteria for SSc. Skin biopsy was done and revealed histological appearance of scleredema. Investigations were done for disease association with scleredema. The patient was not diabetic, antistreptolysin O titer was normal, serum protein electrophoresis, immunofixation and bone marrow biopsy were done, and the patient was diagnosed as scleredema associated with immunoglobulin A kappa multiple myeloma. Treatment by combination of bortezomib, cyclophosphamide, and dexamethasone was started with marked clinical and hematological improvement.

CONCLUSION

Many conditions mimic SSc including scleredema, which may be the initial presentation of multiple myeloma. Rheumatologists and dermatologists should be able to recognize these conditions to provide the suitable management and follow-up for these patients.

Coexistence of scleroderma with multiple myeloma: a rare association

Coexistence of scleroderma with multiple myeloma (MM) is an unusual finding with unclear significance. Only 13 cases of MM with scleroderma have been reported until now. We report a case of a 24-year-old man with 8-year history of progressive thickening of skin all over the body. Histopathology of skin lesion was consistent with scleroderma. Bone marrow biopsy showed interstitial and focal increase in plasma cells and increased bone marrow fibrosis. Skeletal survey showed osteopenia, but no osteolytic lesion or fracture. The patient was diagnosed as scleroderma with coexistence of immunoglobulin A, κMM. The patient recovered with improvement of skin lesions after 9 months of therapy with thalidomide and dexamethasone.

FGF-R3 and OPG expression in patient with multiple myeloma following systemic sclerosis: case report and review of the literature

The presence of multiple myeloma (MM) in a patient with systemic sclerosis is a rare and unusual occurrence with unclear significance. We report the case of a 55-year-old woman with a 20-year history of systemic sclerosis, who subsequently presented with clinical stage IIIA IgG-λ MM. The systemic sclerosis was diagnosed and treated in 1988 with D: -penicillamine and methotrexate. Twenty years later, in December 2008, she presented with symptoms of Raynaud's phenomenon and intense facial pruritus. Immunoelectrophoresis confirmed the presence of a IgG-λ paraprotein (71.90 g/l) and Bence Jones proteinuria of the lambda light chains. Bone marrow histology revealed infiltrates of plasmocytes and lymphoplasmocytes which were on immunohistochemistry CD38+, FGF-R3+ and OPG+. An extensive X-ray skeletal survey did not show any osteolytic lesions or fractures. The patient was treated according to the CTD protocol (cyclophosphamide, thalidomide, and dexamethasone) which was effective against the myeloma as well as the systemic sclerosis and patient achieved complete remission.

From scleredema to AL amyloidosis: disease progression or coincidence? Review of the literature

Scleredema (also called scleredema of Buschke) is a fibromucinous connective tissue disorder of unknown cause that belongs to a group of scleroderma-like disorders. We report the case of a 64-year-old lady with long-standing scleredema, associated with a paraprotein, and progressing to multiple myeloma and AL amyloidosis. The relationship of scleredema with paraprotein and multiple myeloma is well established, but only two cases of scleredema associated with amyloidosis have been reported to date. We suggest that amyloidosis may be underdiagnosed in patients with scleredema and paraproteinaemia. Features attributed to extracutaneous manifestations of scleredema could represent systemic amyloidosis. We review published reports of scleredema associated with paraprotein and discuss the difficulties in the differential diagnosis of scleroderma-like disorders. We discuss the diagnosis of plasma cell dyscrasias and amyloidosis and their relevance in rheumatology practice.

Biomechanical measurement of skin distensibility in scleredema of Buschke associated with multiple myeloma

We report a case of scleredema of Buschke associated with IgG kappa monoclonal hypergammaglobulinaemia. After myeloma polychemotherapy an improvement in skin involvement was observed and confirmed by means of noninvasive skin elasticity measurements. This suggests a relationship between the two diseases. The bioengineering method used can be useful for early detection and monitoring the skin involvement in patients with this disease association.