J Korean Med Sci.  2005 Aug;20(4):699-701. 10.3346/jkms.2005.20.4.699.

Cerebral Infarction in IgG Multiple Myeloma with Hyperviscosity

• Park MS
• Kim BC
• Kim IK
• Lee SH
• Choi SM
• Kim MK
• Lee SS
• Cho KH

• KMID: 1712760
• DOI: http://doi.org/10.3346/jkms.2005.20.4.699

Abstract

Cerebral infarction is an uncommon complication in multiple myeloma with hyperviscosity. Serum hyperviscosity may cause a variety of clinical manifestations including bleeding from mucosal membranes, congestive heart failure, retinopathy, and various neurologic deficits. These manifestations have been attributed to the presence of large quantities of asymmetrical molecules of high molecular weight in the serum. We recently experienced a case of multiple myeloma with acute cerebral infarction, which caused by hyperviscosity, as an initial manifestation in IgG multiple myeloma, and reviewed the relevant literature of myeloma presenting with the stroke. A 68-yr-old woman abruptly developed hypesthesia and monoplegia in the left leg. The stroke confirmed by the brain MRI and MR angiography, which revealed acute infarction at the right anterior cerebral artery territory. On admission, routine blood tests showed a slight decrease in hemoglobin and a marked increase in erythrocyte sedimentation rate. Peripheral blood smear, serum protein electrophoresis, serum visocity, and bone marrow aspiration showed that she had IgG multiple myeloma with hyperviscosity. She was treated by chemotherapy with cyclophosphamide and discharged with the improved clinical condition.

Keyword

Multiple Myeloma; Immunoglobulin G; Cerebral Infarction; Hyperviscosity

MeSH Terms

Aged
*Blood Viscosity
Cerebral Infarction/*blood
Electrophoresis
Female
Humans
Immunoglobulin G/*blood
Magnetic Resonance Imaging
Multiple Myeloma/*diagnosis/immunology

Figure

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  Fig. 1 T2-weighted (A) and diffusion-weighted (B) axial MRI scans show acute cerebral infarction on the callosomarginal territory of right anterior cerebral artery. MR angiography (C) has no stenosis on intracranial arteries.

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  Fig. 2 Serum protein electrophoresis (SPEP) shows a sharp peak in the gamma globulin region. Relative fraction of gamma globulin region on SPEP was 42.6% of the total (9.3 g/dL).

Reference

1. Fahey JL, Barth WF, Solomon A. Serum hyperviscosity syndrome. JAMA. 1965. 192:464–467.

2. Mehta J, Singhal S. Hyperviscosity syndrome in plasma cell dyscrasias. Semin Thromb Hemost. 2003. 29:467–471.

3. Crawford J, Cohen HJ. Ritzman SE, editor. Disorders of hyperviscosity. Pathology of immunoglobulins: diagnostic and clinical aspects. 1982. New York: Alan R Liss;237–259.

4. Kim PJ, Han JY, Kim TG, Ahn JG, Lee KH, Kim HS, Ji C, Lee KS. A case of multiple myeloma presented with a bulky cranial plasmacytoma invading cerebrum. Korean J Hematol. 1999. 34:477–481.

5. Mueller J, Hotson JR, Langston JW. Hyperviscosity-induced dementia. Neurology. 1983. 33:101–103.

6. Solerte SB, Ceresini G, Ferrari E, Fioravanti M. Hemorheological changes and overproduction of cytokines from immune cells in mild to moderate dementia of the Alzheimer's type: adverse effects on cerebromicrovascular system. Neurobiol Aging. 2000. 21:271–281.

7. Coull BM, Beamer N, de Garmo P, Sexton G, Nordt F, Knox R, Seaman GV. Chronic blood hyperviscosity in subjects with acute stroke, transient ischemic attack, and risk factors for stroke. Stroke. 1991. 22:162–168.

8. Mori K, Hasegawa J, Hayafuji M, Yokota S, Narita M, Otagiri T. Multiple cerebral infarction during anesthesia in patient with hypergammaglobulinemia. Masui. 1998. 47:217–220.

9. Longo DL. Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, editors. Plasma cell disorders. Harrison's principles of internal medicine. 2001. 15th ed. International edition. McGraw-Hill;727–733.

10. Pruzanski W, Watt JG. Serum viscosity and hyperviscosity syndrome in IgG multiple myeloma. Ann Intern Med. 1972. 77:853–860.

11. Preston FE, Cooke KB, Foster ME, Winfield DA, Lee D. Myelomatosis and the hyperviscosity syndrome. Br J Haematol. 1978. 38:517–530.

12. Lindsley H, Teller D, Noonan B, Peterson M, Mannik M. Hyperviscosity syndrome in multiple myeloma: a reversible, concentration-dependent aggregation of the myeloma protein. Am J Med. 1973. 54:682–688.

13. Kaloterakis A, Filiotou A, Konstantopoulos K, Rombos Y, Bossinakou I, Hadziyannis S. Multiple myeloma in sickle cell syndromes. Haematologia. 2001. 31:153–159.

14. Wang CJ, Cheng KI, Soo LY, Tang CS. Intraoperative stroke under epidural anesthesia for bipolar hemiarthroplasty in a patient with multiple myeloma: a case report. Kaohsiung J Med Sci. 2001. 17:55–59.