Acute Gastrointestinal Hemorrhage in a Multiple Myeloma Patient Due to Gastric Plasmacytomas

Abstract

Introduction: A plasmacytoma is a solitary mass of plasma cells that forms either in the skeletal system as a solitary plasmacytoma of bone (SPB) or in soft tissues as an extramedullary plasmacytoma (EP). 80% of EP are found in the upper respiratory tract and only about 2-5% of these lesions are found in the stomach. Even when gastric plasmacytomas (GP) are found they are rarely the cause of acute gastrointestinal bleed (GIB). We present a rare cause of acute upper GIB in patient with known multiple myeloma (MM). Case Report: 50 year old man had a recurrence of MM for which he received chemotherapy (etoposide, prednisone, oncovin, cylophosphamide, hydroxydaunorubicin). At follow-up 2 days post discharge, he reported having dark stools associated with progressive fatigue, lightheadedness, and mild nonspecific abdominal discomfort. The patient was found to have a heart rate of 102 beats per min and a blood pressure of 107/60 mm Hg. Mild epigastric tenderness to deep palpation without rebound or guarding was elicited on abdominal exam. Digital rectal exam showed brown stool that was positive for occult blood. Laboratory data: hemoglobin 5.8 g/dl (Normal: 10.9-13.4 g/dl), 2 days prior his hemoglobin was 7.5 g/dl. On esophagogastrodudnoscopy (EGD) 2 large (20 mm x 20 mm) polypoid lesions with cratered ulcers that were filled with necrotic tissue were seen in the gastric body (See Image 1 - 2). Smaller polypoid lesions with central umbilications were noted throughout the gastric body and antrum. Biopsies of the lesions showed loose clusters of plasma cells with only lambda light chains in the lamina propria which were positive for CD138 and negative for CD56, which were consistent with his known MM. A positron emission tomography-computed tomography was done which showed progression of his disease but in particular a new hypermetabolic focus of activity was seen in the gastric wall compatible with an active tumor. The patient was diagnosed with a GP and responded well to pantoprazole twice a day and was to follow up with his oncologist. Conclusion: MM is a neoplastic proliferation of a single plasma cell producing a monoclonal immunoglobulin. Our patient had disease progression which was found after his evaluation for GIB when multiple GPs were seen on EGD. Management for GPs includes surgery and/or radiotherapy although the combination of surgery and radiotherapy may yield superior results.Figure 1Figure 2