Multiple myeloma invasion of the central nervous system
Authors: Marjanovic Slobodan , Mijuskovic Zoran , Stamatovic Dragana , Madjaru Lavinika , Ralic Tijana , Trimcev Jovana , Stojanovic Jelica , Radovic Vesna 
Published: February 2012

Introduction. Multiple myeloma (MM) is characterized by the presence of
neoplastic proliferating plasma cells. The tumor is generally restricted to
the bone marrow. The most common complications include renal insufficiency,
hypercalcemia, anemia and reccurent infections. The spectrum of MM
neurological complications is diverse, however, involvement of MM in the
cerebrospinal fluid (CSF) and leptomeningeal infiltration are rare
considered. In about 1% of the cases, the disease affects the central nervous
system (CNS) and presents itself in the form of localized intraparenchymal
lesions, solitary cerebral plasmocytoma or CNS myelomatosis (LMM). Case
report. We presented the clinical course of a 55-year-old man with MM and LMM
proven by malignant plasma cells in the CSF, hospitalized with the pain in
the thoracic spine. His medical history was uneventful. There had been no
evidence of mental or neurological impairment prior to the seizures. Physical
examination showed no abnormalities. After a complete staging, the diagnosis
of MM type biclonal gammopathia IgG lambda and free lambda light chains in
the stage III was confirmed. The treatment started with systemic chemotherapy
(with vincristine, doxorubicin plus high-dose dexamethasone - VAD protocol),
radiotherapy and bisphosphonate. The patient developed weakness, nausea,
febrility, dispnea, bilateral bronchopneumonia, acute renal insufficiency,
confusions, headaches and soon thereafter sensomotor aphasias and right
hemiparesis. The patient was treated with the adequate therapy including one
hemodyalisis. His neurological status was deteriorated, so Multislice
Computed Tomography (MSCT) of the head was performed and the findings were
normal. Analysis of CSF showed pleocytosis, 26 elements/ mL and increased
concentrations of proteins. Cytological analysis revealed an increased number
of plasma cells (29%). Electrophoretic analysis of proteins disclosed the
existance of monoclonal components in the serum, urine and CSF.
Immunofixation electrophoretic and quantitative nephelometric tests confirmed
Biclonal multiple myeloma of IgG lambda and light chain lambda isotypes.
Analysis of neurothropic viruses with ELISA methods was negative. Once the
presence of LMM was confirmed, the patient received intrathecal chemotherapy
with methotrexate, cytosine arabinoside, dexamethasone three times a week,
and systemic high doses of dexamethasone iv like a single agent without
craniospinale irradiations. Despite the treatment, the patient died one month
after the diagnosis. Autopsy was not performed. Conclusion. Presented
patient, as well as most other patients with MM progressing to CNS
infiltration was in the stage III. In addition to the detailed clinical
examination, and all investigations required for MM diagnosis and staging of
the disease, we introduced the additional CSF examination and calculation of
kappa lambda ratio, that helped us make an early diagnosis and prognosis of
MM with LMM. Although LMM had a low prevalence, it could be more frequent
than expected especially in patients with high risk. CSF examination with
positive plasma cells and abnormal morphology remains the hallmark for
diagnosing CNS infiltration.