Multiple Myeloma Involving Skin and Pulmonary Parenchyma after Autologous Stem Cell Transplantation
© Yuan et al; licensee BioMed Central Ltd. 2009
Received: 5 July 2009
Accepted: 13 November 2009
Published: 13 November 2009
Pulmonary involvement and skin involvement are rare complications of plasma cell neoplasms. Here we describe what may be the first reported case of a patient with relapse in both of these sites following autologous peripheral blood stem cell transplantation.
We report a 58-year-old man with diffuse pulmonary parenchymal plasma cell infiltration and skin nodules. Five years previously he had been treated successfully with VAD (vincristine, adriamycin and dexamethasone) chemotherapy and an autologous peripheral blood stem cell transplant for multiple myeloma. Four years later he relapsed with anemia, hypercalcemia, and an IgG of 6170 mg/dl. Skeletal survey showed no lytic lesions, the marrow was 30% infiltrated by plasma cells with a t(11;14)(q13;q32) and a del 13q14.3 abnormality. The paraprotein level transiently responded to thalidomide-dexamethasone, but he in turn developed hyperammonemia, which responded to the addition of bortezomib and liposomal pegylated doxorubicin to the regimen.
In plasma cell neoplasms, pulmonary complications are common, but infection is the most common cause. In a series of 958 patients with myeloma, 10% had pulmonary findings, but in only 1 case was plasma cell involvement demonstrated histologically, and the clinical course was suggestive of plasma cell involvement in only 3 other cases . In the literature, there are additional cases of pulmonary involvement: some of these had advanced or treatment-refractory disease, like our patient [2–4], whereas in several cases, the lung was the initial site of presentation [5–8]. Likewise, skin involvement is rare, but this too has been reported [9, 10]. We believe that this is the first case patient reported to have both sites of involvement as a complication of relapsed disease after autologous stem cell transplantation. The presence of circulating plasma cells and hyperammonemia are both known to be indicators of advanced disease. Plasma cell neoplasm should be kept in the differential diagnosis of any pulmonary infiltrate not responding to antibiotics or as a possible cause of skin nodules in a patient with a history of myeloma, plasmacytoma, or MGUS.
The Institutional IRB approved the submission of this manuscript, which was considered by the editors to be a proxy for the patient's informed consent for the publication of the manuscript and accompanying images, in light of the fact that the patient had expired. A copy of the written documentation of this is available for review by the Editor-in-Chief of this journal.
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