Association of multiple myeloma and inflammatory bowel diseases

To the Editor, Reynolds et al [1] recently reviewed the literature about multiple myeloma (MM) occurring in the setting of inflammatory bowel disease (IBD) and reported the case of a patient who had developed MM after being treated with infliximab (Remicade) for Crohn’s disease. In their report, the patient had been treated with infliximab for 5 years with escalating doses. Patient’s infliximab was discontinued due to lack of efficacy. One month after the patient’s infliximab was discontinued, she was found to have stage III MM. The authors also reviewed the literature and found a total of eight reported cases of MM associated with inflammatory bowel disease between 1977 and the present time. The authors discussed the various potential mechanisms for such an association of MM to IBD and its treatment. In our practice, we have encountered two patients who were treated with infliximab or daclizumab (Zenepax) for Crohn’s disease and ulcerative colitis (UC), respectively, and both were subsequently diagnosed with MM. Case 1: A 49-year-old African American female who was diagnosed with UC 14 years prior to the diagnosis of stage III A IgG kappa MM. Her myeloma related symptoms began while she was treated with daclizumab for her UC on a phase III randomized trial. The treatment with daclizumab was stopped because of lack of response and then treated with mesalamine (Asacol) with clinical improvement. However, she continued to lose weight and developed progressive pain in her rib cage, back and right hip. Elevated total protein was noted and subsequent evaluation led to the diagnosis of MM. She was treated with induction therapy using VAD combination (Vincristine, adriamycin and dexamethasone) followed by autologous stem cell transplantation (ASCT). She has been in clinical remission for the last 3 years. Her UC has been quiet since the treatment for MM began and without any specific treatment. Case 2: A 50-year-old white male who was diagnosed with ankylosing spondylitis and Crohn’s disease 6 years prior to the diagnosis of stage IIIA IgG lambda MM. He had terminal ileum resection at another facility due to gastrointestinal bleeding from small bowel ulcerations. About one year prior to the diagnosis of MM, he completed therapy with infliximab for recurrent symptoms and reportedly had a good response. At that time, he had thrombocytopenia and anemia with fatigue and evaluation revealed small serum monoclonal protein of 0.15 gr/dl. He was monitored periodically; however, he developed right chest pain and chest X-ray revealed pleural-based mass which was confirmed on computerized tomography (CT) to be a 2.8 · 1.6 cm mass originating from the adjacent rib. CT guided biopsy was interpreted as a small round blue cell tumor. He was found to have other bony lesions and treated with chemotherapy with the diagnosis of sarcoma. He was later referred to our institution for consultation. His diagnosis was corrected to be MM and treated with VAD followed by ASCT. Following a short-lived partial remission, he died about 2 years later from progressive MM. His gastrointestinal symptoms during that time were not significant. Our cases support the temporal association of symptomatic MM to the immunosuppressive treatment of IBD. It is interesting that the diagnosis of MM was determined shortly after infliximab and daclizumab were stopped, but H. Liu J. S. Moreb (&) Department of Medicine, Hematology Oncology Division, University of Florida, Gainesville, FL, USA e-mail: morebjs@medicine.ufl.edu