Nonsecretory Multiple Myeloma Presenting with Gastrointestinal Bleeding- a Case Report

Abstract

Introduction: Multiple myeloma (MM) is a malignant neoplasm of plasma cells. Nonsecretory multiple myeloma (NSMM) is a rare variant that accounts for 1-5% of all cases of MM. It is characterized by absence of monoclonal immunoglobulins in serum and urine protein electrophoresis. Extramedullary involvement has been reported in up to 20% of the cases of MM. Gastrointestinal (GI) involvement in MM is extremely rare (0.9%) and GI hemorrhage is occasionally reported. To the best of our knowledge, this is the first reported case of NSMM presenting with GI bleeding and involving multiple distinct sites of GI tract.Figure 1Figure 2Figure 3Case: A 64-year-old male presented with two-week history of hematochezia and fatigue. He was diagnosed with true NSMM a year previously. He completed five cycles of Bortezomib, Cyclophosphamide, and Dexamethasone (VCD) with minimal response and was switched to Lenalidomide and Dexamethasone. He was hemodynamically stable. Laboratory data showed Hemoglobin of 5.5 g/dl, Platelets 26000/ul, Blood Urea Nitrogen 9 mg/dl and INR 1.1. Esophagogastroduodenoscopy and Colonoscopy revealed multiple punctate ulcerations of the stomach, a duodenal bulb nodule and diffuse colonic ulcerations. Histopathology of all the biopsied lesions showed extensive mucosal infiltration by atypical monoclonal plasma cells. Despite transfusions he continued to have intermittent bleeding. He was deemed a poor candidate for further chemotherapy and opted for hospice care. Discussion: NSMM is a rare entity of MM. Gastrointestinal spread is an unusual phenomenon in MM, but where it does occur, small intestine is the most commonly involved site, followed by stomach, colon and esophagus. Endoscopically, morphology of GI plasmacytomas ranges from discrete ulcers, infiltrative masses, and nodules to polypoid lesions. Diagnosis is made on histopathology with plasma cell infiltration. Treatment of GI plasmacytomas remains the same as for systemic MM. Chemoradiation therapy and hematopoietic stem cell transplantation are the mainstay of treatment, and surgery is typically reserved for complications. The prognosis of MM patients with GI involvement has been reported to be poor despite aggressive measures. Conclusion: Although GI plasmacytomas are uncommon, they must be considered in the differential diagnosis of patients with GI symptoms, especially those with a prior history of MM. Endoscopic evaluation and histopathological examination is crucial for early diagnosis and further intervention.