A Rare Cause of Gastrointestinal Bleeding

Abstract

She was admitted for pleural biopsy. However, an episode of gastrointestinal bleeding with passage of melena occurred before the biopsy. Laboratory studies revealed normal leucocyte count with lymphocytosis (white blood count, 7460/μL; lymphocyte, 59.1%); hemoglobin, 10.7 g/dL; creatinine, 0.5 mg/dL; alanine aminotransferase, 28 IU/L; serum albumin, 2.9 g/dL; globulin, 4.3 g/dL; lactate dehydrogenase, 311 IU/L; and normal carcinoembryonic antigen (3.62 ng/mL). Esophagogastroduodenoscopy revealed multiple polypoid nodules with overlying ulcers and mucosal friability, extending from the cardia and body to the antrum of stomach (Figure B). Two additional polyps were detected at second portion of duodenum (Figure C). Biopsies were performed.What is the most likely diagnosis?See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.Answer to the Clinical Challenges and Images in GI Question: Image 1: Multiple Myeloma With Extramedullary Gastroduodenal PlasmacytomaView Large Image Figure ViewerDownload Hi-res image Download (PPT)Gastrointestinal plasmacytoma had been described in 1966.1Goldstein W.B. Poker N. Multiple myeloma involving the gastrointestinal tract.Gastroenterology. 1996; 51: 87-93Abstract Full Text PDF Google Scholar Endoscopic features of this disease are difficult to differentiate from lymphoma and amyloidosis, so pathology is mandatory for an accurate diagnosis. Solitary extramedullary (gastric) plasmacytomas have less bone marrow involvement and result in better outcomes. However, gastrointestinal involvement of multiple myeloma is a sign of aggressive biological features.2Talamo G. Cavallo F. Zangari M. et al.Clinical and biological features of multiple myeloma involving the gastrointestinal system.Haematologica. 2006; 91: 964-967PubMed Google Scholar Extensive extramedullary involvements of multiple myeloma, as in our patient, are generally fatal.3Liebross R.H. Ha C.S. Cox J.D. et al.Clinical course of solitary extramedullary plasmacytoma.Radiother Oncol. 1999; 52: 245-249Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar She was admitted for pleural biopsy. However, an episode of gastrointestinal bleeding with passage of melena occurred before the biopsy. Laboratory studies revealed normal leucocyte count with lymphocytosis (white blood count, 7460/μL; lymphocyte, 59.1%); hemoglobin, 10.7 g/dL; creatinine, 0.5 mg/dL; alanine aminotransferase, 28 IU/L; serum albumin, 2.9 g/dL; globulin, 4.3 g/dL; lactate dehydrogenase, 311 IU/L; and normal carcinoembryonic antigen (3.62 ng/mL). Esophagogastroduodenoscopy revealed multiple polypoid nodules with overlying ulcers and mucosal friability, extending from the cardia and body to the antrum of stomach (Figure B). Two additional polyps were detected at second portion of duodenum (Figure C). Biopsies were performed. What is the most likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Answer to the Clinical Challenges and Images in GI Question: Image 1: Multiple Myeloma With Extramedullary Gastroduodenal PlasmacytomaGastrointestinal plasmacytoma had been described in 1966.1Goldstein W.B. Poker N. Multiple myeloma involving the gastrointestinal tract.Gastroenterology. 1996; 51: 87-93Abstract Full Text PDF Google Scholar Endoscopic features of this disease are difficult to differentiate from lymphoma and amyloidosis, so pathology is mandatory for an accurate diagnosis. Solitary extramedullary (gastric) plasmacytomas have less bone marrow involvement and result in better outcomes. However, gastrointestinal involvement of multiple myeloma is a sign of aggressive biological features.2Talamo G. Cavallo F. Zangari M. et al.Clinical and biological features of multiple myeloma involving the gastrointestinal system.Haematologica. 2006; 91: 964-967PubMed Google Scholar Extensive extramedullary involvements of multiple myeloma, as in our patient, are generally fatal.3Liebross R.H. Ha C.S. Cox J.D. et al.Clinical course of solitary extramedullary plasmacytoma.Radiother Oncol. 1999; 52: 245-249Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar Gastrointestinal plasmacytoma had been described in 1966.1Goldstein W.B. Poker N. Multiple myeloma involving the gastrointestinal tract.Gastroenterology. 1996; 51: 87-93Abstract Full Text PDF Google Scholar Endoscopic features of this disease are difficult to differentiate from lymphoma and amyloidosis, so pathology is mandatory for an accurate diagnosis. Solitary extramedullary (gastric) plasmacytomas have less bone marrow involvement and result in better outcomes. However, gastrointestinal involvement of multiple myeloma is a sign of aggressive biological features.2Talamo G. Cavallo F. Zangari M. et al.Clinical and biological features of multiple myeloma involving the gastrointestinal system.Haematologica. 2006; 91: 964-967PubMed Google Scholar Extensive extramedullary involvements of multiple myeloma, as in our patient, are generally fatal.3Liebross R.H. Ha C.S. Cox J.D. et al.Clinical course of solitary extramedullary plasmacytoma.Radiother Oncol. 1999; 52: 245-249Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar Supplementary MaterialeyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlNDY1MWVmMjIwNDczMzY2ZGRhNDJlMWQyOWI2ZWQ2NiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjY3NzAxMDk5fQ.okWjpkAPWciwWrPy8fsvjnpqyRTzOVPajqd_tMCI-Glgedi9nZApdCAfOeDvWoLV1CY3pV1X0EMbQbqUXvK9XgYaDcaNcBfFFPPj2VgLPuiElDp1n2v79I69s1LpsG68YTDz-DM_hvY4Lw3ZpSbXs9KnStY8IGCDdkhtSv-4ge5o_Js8fVaqARoVqy3glHekmSAU0XeIfAKbSLS4shBHHyrsPHSdBxKjbm2AibdOoDz700gdnzuPN8lKKyEUtykp190bKtgIc_LttaqwFGXMlwPL87V-5evrsFtX6mGwXpoHlTHHgQhy6kovTJ1SoVu6L9Aw1tKP9_ayvPq06D6Zuw Download .mp4 (10.24 MB) Help with .mp4 files Video 1 eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlNDY1MWVmMjIwNDczMzY2ZGRhNDJlMWQyOWI2ZWQ2NiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjY3NzAxMDk5fQ.okWjpkAPWciwWrPy8fsvjnpqyRTzOVPajqd_tMCI-Glgedi9nZApdCAfOeDvWoLV1CY3pV1X0EMbQbqUXvK9XgYaDcaNcBfFFPPj2VgLPuiElDp1n2v79I69s1LpsG68YTDz-DM_hvY4Lw3ZpSbXs9KnStY8IGCDdkhtSv-4ge5o_Js8fVaqARoVqy3glHekmSAU0XeIfAKbSLS4shBHHyrsPHSdBxKjbm2AibdOoDz700gdnzuPN8lKKyEUtykp190bKtgIc_LttaqwFGXMlwPL87V-5evrsFtX6mGwXpoHlTHHgQhy6kovTJ1SoVu6L9Aw1tKP9_ayvPq06D6Zuw Download .mp4 (10.24 MB) Help with .mp4 files Video 1