Abstract
Purpose: INTRODUCTION: Primary or secondary involvement of the GI tract by plasma cell dyscrasias is exceptionally rare. We hereby present the case report of a gastric plasmacytoma that had a unique and novel presentation of jaundice. CASE DESCRIPTION: A 68 y/o female with h/o HTN, recurrent DVT, and asthma presented with abdominal pain for two weeks. Pain was associated with nausea, occasional vomiting and yellowish discoloration of skin and sclera. She denied any weight loss or itching. Abdominal exam showed mild distension, hepatomegaly and right upper quadrant tenderness. Laboratory results showed creatinine 1.8 mg/dl, Hgb 6.1g/dl, MCV 112.8, platelet count 45000cells/cubic millimeter, albumin 2.5 g/dl, total bilirubin 4.0 umol/l, direct bilirubin 2.9 umol/l, ALP 209 U/L, AST 75 U/L and ALT 36 U/L. Chest X-ray showed an abnormal lesion on the right 6th rib. Abdominal ultrasound showed coarsened echotexture of the liver, gall bladder sludge, perihepatic ascites and no cholecystitis. MRCP showed nodular liver without any significant gallbladder or CBD findings. EGD showed a nodule at the incisura of the stomach and a non bleeding ulcer. Histopathology of the gastric nodule revealed hyperplastic foveolar polyp containing a nodular cluster of plasma cells. Immunohistochemistry was consistent with a nodular collection of predominantly lambda positive cells in the lamina propria diagnostic of gastric plamacytoma. Bone marrow biopsy and flow cytometry analysis were interpreted as marked cell dyscrasia, diffuse marrow infiltration with monoclonal IgG/lambda + plasma cells. Immunohistochemistry showed that 90-95% of the nucleated cells in the biopsy were CD138 positive. DISCUSSION: Multiple Myeloma (MM) involves GI tract only in about <5% of the cases. Gastrointestinal involvement rarely is the first or sole presenting symptom of extramedullary MM. It is either an incidental finding or manifests as a secondary system involvement. Liver is the most commonly involved site followed by the small intestine, pancreas, stomach, peritoneum and colon. Gastric plamacytoma has a varied endoscopic appearance of thickened folds, polyposis, ulcers and multiple nodules. Differential diagnoses include amyloidosis, poorly differentiated neoplasms, MALT lymphoma and GIST. Tissue pathology including flow cytomtery and immunohistochemistry play a vital role in diagnostic differentiation. Complete resection of the gastric lesion is usually recommended with or without combination with irradiation or chemotherapy. Gastric or any extra nodal involvement in a patient with multiple myeloma carries a poor prognosis.
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