Pleural myelomatous involvement in multiple myeloma: five cases

Immunoglobulin E (IgE)-Mediated Multiple Myeloma Presenting as Pleural Effusion

Multiple myeloma (MM) is a disease characterized by the abnormal production of plasma cells. These plasma cells have the property to produce immunoglobulins (Ig), on the basis of which MM can be classified. Immunoglobulin G is responsible for most of the cases, while IgE mediates the rarest form of MM. Since the first case was reported in 1967, knowledge regarding IgE-mediated MM is based on individual case reports. Based on the information available, it is thought that IgE-mediated MM presents clinically with the involvement of renal, bone, and hematological symptoms, which are the same as any other myeloma. However, the MM rarely involves the pleura, leading to malignant pleural effusion. We present a case of IgE-mediated MM with a unique feature of pleural effusion. The patient presented with constitutional symptoms of MM, which were followed by lab investigations revealing low hemoglobin, hypercalcemia, and high creatinine levels. An incidental computed tomography angiography (CTA) revealed lytic lesions in the spine. This was followed by skull and chest X-rays as part of the workup to determine the extent of the disease. It revealed further lytic lesions in the skull, humerus, and scapula, along with pleural effusion. This led to the suspicion of MM, which was ultimately confirmed by serum protein electrophoresis and a bone marrow biopsy. The patient was started on a triple regimen of bortezomib, thalidomide, and dexamethasone, which led to substantial improvement in his symptoms.

Myelomatous pleural effusion in a cat diagnosed with multiple myeloma

Case summary

A 10-year-old male castrated domestic shorthair cat was presented with a 3-day history of dyspnoea, chronic lethargy and inappetence. A bilateral pleural effusion was identified by thoracic ultrasound, and cytological examination revealed numerous atypical plasma cells. Biochemistry and serum protein electrophoresis revealed a severe hyperglobulinaemia associated with a monoclonal gammopathy. A moderate non-regenerative anaemia was also noted. Multiple bone lytic lesions were detected, and marked plasmacytosis was observed on bone marrow aspirates. Chemotherapy with cyclophosphamide and prednisolone was initiated but did not result in any clinical or biological response, and pleural effusion recurred. Lack of therapeutic response led to euthanasia 2 months after diagnosis.

Relevance and novel information

This is the first description of a myelomatous pleural effusion in a cat diagnosed with multiple myeloma and should be considered as one of the possible differential diagnoses for cats presented with pleural effusion and hyperglobulinaemia. The diagnostic, therapeutic and prognostic aspects of this manifestation are discussed.

Myelomatous Pleural Effusion: A Rare Case Report and Literature Review

Multiple myeloma (MM) is typically characterized by the neoplastic proliferation of plasma cells producing a monoclonal immunoglobulin. Pleural effusion in MM is uncommon and usually caused by heart failure, pulmonary embolus, and nephrotic syndrome [Arch Intern Med. 1978;138(5):727-30; Chest. 1994;105(2):622-4]. Here, we report a case of myelomatous pleural effusion as part of the initial presentation of MM in a patient with the IgG-lambda subtype, which is extremely uncommon.

Myelomatous ascites and pleural effusion in relapsed multiple myeloma

Extramedullary multiple myeloma is seen in advanced and aggressive disease and occurs due to plasma cell infiltration of sites other than the bone marrow. Myelomatous ascites or pleural effusion is seen in less than 1% of cases and can be differentiated from infectious etiologies based on fluid cytology.

Pleural effusion-based nomogram to predict outcomes in unselected patients with multiple myeloma: a large single center experience

Pleural effusion (PE) is prevalent in unselected "real-life" populations of multiple myeloma (MM). However, its prognostic value on MM is currently elusive. This study aimed to explore the role of PE on MM prognosis and to develop a novel prognostic nomogram for a cohort of Chinese patients with MM. Patients diagnosed with MM form 2000 through 2017 were retrospectively enrolled. PE was evaluated by chest computed tomography (CT) scans. Independent predictors of overall survival (OS) were identified using a multivariable Cox regression model performed on variables selected by the least absolute shrinkage and selection operator (LASSO) algorithm. A nomogram was constructed based on these variables. The concordance index (C-index) and the calibration curve were used to evaluate the predictive performance of the nomogram. Among 861 patients analyzed, 368 patients developed PE. Multivariate cox regression and restricted mean survival time (RMST) analyses revealed that patients with PE experienced worse OS vs. patients without PE. A nomogram predictive of OS was constructed using PE, plasma cell proportion, international staging system (ISS) stage, Charlson comorbidity index (CCI), 1q21 gain, and autologous hematopoietic stem cell transplantation (HSCT). The nomogram showed satisfactory discrimination in the derivation cohort (C-index=0.729) and the validation cohort (C-index=0.684), outperforming the Durie-Salmon (DS) and ISS staging systems. Moreover, the nomogram accurately classified patients into two distinct high- and low-risk groups. PE is frequently encountered in the disease course for MM patients. We derivated and validated a novel nomogram for MM based on PE, outperforming the DS/ISS staging systems.

Pleural effusion in 11:14 translocation q1 multiple myeloma in the setting of proteasome inhibitor presents therapeutic complexity

Background

Primary malignant pleural effusion has been reported in about 134 cases of multiple myeloma (MM). Associated pleural effusions in cases of MM portend a poor prognosis and identifying them is highly relevant. Reported is the case of a man diagnosed with MM who developed primary myelomatous pleural effusion in the setting of multiple relapses and subsequent mortality within 2 months of the pleural effusion diagnosis.

Presentation

A 61-year-old African American man was diagnosed with MM in 2011. He received induction therapy of lenalidomide and dexamethasone and an autologous stem cell transplant in 2012. Over the next 5 years, the patient went through alternating periods of remission and relapse that were treated with two rounds of thoracic spine radiation therapy and chemotherapeutic agents. In September 2017, the patient presented with worsening dyspnea and was found to have pleural effusion. Fluid analysis showed plasma cell dyscrasia. Fluid drainage was performed, then the patient was discharged after 1 week which was followed by rapid re-accumulation of fluid and rehospitalization about 10 days after discharge. The patient passed away a few weeks after the second admission.

Conclusion

Pleural effusion carries a differential diagnosis which may include malignancy but is commonly thought to be less specific to multiple myeloma but should still remain in the differential diagnosis. To our knowledge, this is the first case of myelomatous pleural effusion (MPE) that was reported after multiple relapses of MM. MPE is a very rare complication of MM, and its presence is a strong indicator of imminent mortality and need for comfort care in case of multiple relapses. End-stage pleural effusion in MM in the setting of proteasome inhibitor adds more therapeutic and diagnostic challenges.

Cytology and clinical features of myelomatous pleural effusion: Three case reports and a review of the literature

The purpose of this study was to report the clinical features, laboratory findings, and cytomorphology, and prognosis of three patients with myelomatous pleural effusion (MPE). The literature pertaining to MPE was reviewed. The three cases and literature review suggest that MPE is rare and often associated with a poor prognosis. The correct diagnosis depends on the aggressive clinical characteristics, laboratory findings, and chromosomal abnormalities, but routine pathological examination of the pleural effusion has low sensitivity. Cell blocks stained with hematoxylin & eosin and by immunohistochemistry revealed that abnormal proliferation of plasma cells and light chain restrictive expression in MPE may be helpful for improving the detection rate of MPE.