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"url" => "/00257753/unassign/S0025775312001376/v1_201305021159/es/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinical report</span>" "titulo" => "Atypical POEMS syndrome: Report of a patient" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Shanshan Liang, Li Zhang, Chuanmin Tao" "autores" => array:3 [ 0 => array:3 [ "nombre" => "Shanshan" "apellidos" => "Liang" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "Li" "apellidos" => "Zhang" "email" => array:1 [ 0 => "drzhangli2014@sina.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "Chuanmin" "apellidos" => "Tao" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Hematology, West China Hospital, Sichuan University, Chengdu, China" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome de POEMS atípico: presentación de un caso" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0090" class="elsevierStylePara elsevierViewall">POEMS syndrome, represented by five major features of polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder and skin changes, is a paraneoplastic syndrome caused by abnormal proliferation of plasma cells and impaired immune system function sign.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Polyneuropathy (typically demyelinating) and monoclonal plasma cell-proliferative disorder (almost always <span class="elsevierStyleItalic">λ</span>) were the mandatory major criterias. POEMS syndrome needs to be diagnosed by combining clinical symptoms and laboratory indicators. Patients who do not meet the above two mandatory criteria but are still diagnosed with POEMS syndrome, such as M protein-negative patients, can be called atypical POEMS syndrome.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our objective was to provide a comprehensive overview of the current diagnostic landscape for POEMS syndrome, with a particular focus on the significance of M protein in the diagnostic process.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patients who visited in West China Hospital of Sichuan University from 2019 to 2023 and eventually diagnosed with POEMS syndrome were included in our study. Special attention was given to the patients’ initial symptoms and the types of the serum M protein. Demographic data (sex, age); clinical symptoms (the initial symptom and the main clinical symptoms); laboratory examination (the serum M protein types and VEGF levels); diagnosis of patients with POEMS syndrome according to diagnostic criteria were recorded.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Of 48 patients, 32 patients were from outpatient clinics and 16 were inpatients. The inpatients had more detailed medical records and information. The median age was 51 years old with the range 34–74. Thirty patients were male, accounting for 62.5%. A summary of the POEMS syndrome patients who were admitted to our hospital over the past 5 years (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The main first symptom was polyneuropathy in 37 cases, followed by skin changes in 4 cases. The largest proportion of the serum M protein was lgA λ with the percentage of 54.2% (26/48). Of 48 patients, 28 patients were fully recorded. Two patients were not meet the two mandatory diagnostic criteria. 7 patients did not conform to the main diagnostic criteria and 2 cases do not fit to the secondary diagnostic criteria.</p><p id="par0030" class="elsevierStylePara elsevierViewall">No serum M protein was detected in one case, which was called the atypical POEMS syndrome. The main symptoms of the 55-year-old male patient included weakness of both lower limbs, effusion in multiple serous cavities, changes in endocrine function (hypothyroidism), and skin pigmentation. Laboratory tests revealed: Serum protein electrophoresis showed no M protein, immunoglobulin IGA was 3560<span class="elsevierStyleHsp" style=""></span>mg/L (836–2900<span class="elsevierStyleHsp" style=""></span>mg/L), blood light chain kappa/lambda ratio was 1.81(1.50–2.56), urine kappa light chain was 0.09 (<0.02<span class="elsevierStyleHsp" style=""></span>g/L), blood β2 microglobulin was 5.74<span class="elsevierStyleHsp" style=""></span>mg/L (1.0–2.3<span class="elsevierStyleHsp" style=""></span>mg/L); serum VEGF (vascular endothelial growth factor) was 906.41<span class="elsevierStyleHsp" style=""></span>pg/ml (0–142<span class="elsevierStyleHsp" style=""></span>pg/ml); No clonal plasma cells and M protein were found in the current laboratory test results. Imaging examination, PET-CT showed: multiple lesions of abnormally increased glucose metabolism in the bones, partial enlargement of cervical, thoracic and abdominal lymph nodes with increased glucose metabolism, and enlarged spleen with increased glucose metabolism; pathology: infiltration of plasmacytoid cells. He was diagnosed with POEMS syndrome and was treated with bortezomib and dexamethasone, after which his symptoms improved and laboratory tests normalized.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Dispenzieri et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> proposed the first diagnostic criteria for POEMS syndrome and added high levels of VEGF to the 2007 revised version.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> The new diagnostic criteria include polyneuropathy and monoclonal plasma proliferative disorder as mandatory criteria. The main diagnostic criteria include: castlemans disease, sclerotic bone lesions, and elevated VEGF levels; 6 secondary diagnostic criteria include (1) organ enlargement (hepatomegaly, splenomegaly, or lymphadenopathy); (2) excessive extravascular volume (peripheral edema, peritoneal effusion, or pleural effusion); (3) endocrine changes (adrenal gland, thyroid, pituitary function, gonad, parathyroid gland, pancreas) (diabetes or thyroid dysfunction alone cannot be used as diagnostic criteria); (4) hemangioma, plethora, cyanosis and leukonychia); (5) papilledema; (6) thrombocytosis or erythrocytosis. The diagnosis of POEMS needs to meet two mandatory diagnostic criteria, one major diagnostic criterion and one minor diagnostic criterion.</p><p id="par0040" class="elsevierStylePara elsevierViewall">At present, some literatures have reported M protein-negative POEMS syndrome, which poses a challenge for clinical diagnosis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> In fact, POEMS syndrome can have negative M protein or elevated IgA, IgG, κ, λ alone or in combination.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The negative results of M protein may have the following reasons: (1) Insufficient sensitivity of the method for detecting immune protein. Mass spectrometry has advantages in detecting M protein, but it has not been widely used. Currently, the main means of detection of M protein are serum protein electrophoresis (sPEP), immunofixation electrophoresis (sIFE), serum free light chain (sFLC), etc., but for patients with POEMS syndrome, M protein will still be negative when using these traditional detection methods situation occurs. (2) M protein secretion is low and may be in the “pre” stage of the disease or in clinical remission after systemic treatment. (3) Plasma cell neoplasms may present in single or multiple lesions (solitary plasmacytomas or multiple myeloma respectively).</p><p id="par0050" class="elsevierStylePara elsevierViewall">The iStopMM study<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> is an ongoing nationwide screening study for multiple myeloma precursor lesions in Iceland. 75,422 Icelanders aged ≥40 years (51% of the population) were screened for M-protein using serum protein electrophoresis (SPE), immunofixation electrophoresis, and free light chains. The MGUS cohort included 3358 individuals. According to SPEP and IFE, 198 cases (9.8%) were identified as having transient M protein. Studies have found that the prevalence of transient M protein is significantly increased in patients with infections, autoimmune diseases, cancer, and obstructive lung diseases. Concomitant loss of M protein was observed in association with the use of corticosteroids, immunosuppressive drugs, azithromycin, and diuretics). However, there was little relationship between gender, age and type of M protein. When mass spectrometry is used as the benchmark, most individuals with transient M protein based on SPE/IFE are false negative, that is, they still have low levels of M protein in their bodies. The prospective cohort study of iStopMM highlighted the potential of MS to reduce the missed diagnosis of M protein. It also showed that some individuals with M protein below the detection limit of SPEP/IFE were identified as transient M protein by conventional methods.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">At present, the diagnosis of POEMS syndrome is based on the combination of clinical manifestations and laboratory tests. The order of clinical symptoms of the disease is different, and the first diagnosis department is different accordingly, which is easy to cause misdiagnosis by clinicians. Therefore, emphasizing pluralism is of great significance for the diagnosis of this disease.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Statements</span><p id="par0060" class="elsevierStylePara elsevierViewall">By submitting this manuscript for consideration for publication, all authors agree to adhere to S. Karger AG's Editorial and Peer Review policies.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Statement of ethics</span><p id="par0065" class="elsevierStylePara elsevierViewall">The study was approved by the Institutional Ethics Committee of West China Hospital of Sichuan University and complied with Declaration of Helsinki. Written informed consents were obtained from the subjects.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Funding</span><p id="par0070" class="elsevierStylePara elsevierViewall">This study was not supported by any sponsor or funder.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Authors’ contributions</span><p id="par0075" class="elsevierStylePara elsevierViewall">Shanshan Liang: concept, design, definition of intellectual content, literature search, clinical studies, manuscript preparation; Li Zhang and Chuanmin Tao: manuscript review.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Data availability statement</span><p id="par0085" class="elsevierStylePara elsevierViewall">All data generated or analyzed during this study are included in this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres2230833" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1868065" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2230834" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1868066" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Statements" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Statement of ethics" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Funding" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Authors’ contributions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Data availability statement" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-03-06" "fechaAceptado" => "2024-05-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1868065" "palabras" => array:3 [ 0 => "M protein" 1 => "Atypical POEMS syndrome" 2 => "Diagnostic criteria" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1868066" "palabras" => array:3 [ 0 => "Proteína M" 1 => "Síndrome de POEMS atípico" 2 => "Criterios diagnósticos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The order of clinical symptoms of POEMS syndrome is different, and the first diagnosis department is different accordingly, which is easy to cause misdiagnosis by clinicians.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective study was conducted between 2019 and 2023 in West China Hospital. Demographic, clinical and laboratory test indicators data were collected.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Out of a total of 48 patients, 32 patients were from outpatient clinics and 16 were inpatients. The median age was 51 years old, and 30 were male. The most prevalent initial symptom is polyneuropathy (77.1%). 22 out of the 48 patients had an elevated VEGF. The most prevalent serum M protein was lgA λ(54.2%), and one patient had no M protein which could be regarded as the atypical POEMS syndrome.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">At present, the diagnosis of POEMS syndrome is based on the combination of clinical manifestations and laboratory tests. Emphasizing pluralism is of great significance for the diagnosis of this disease.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El orden de los síntomas clínicos del síndrome de POEMS varía y, por lo tanto, el primer departamento de diagnóstico también es diferente, lo que puede causar diagnósticos erróneos por parte de los clínicos.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realizó un estudio retrospectivo entre los años 2019 y 2023 en el Hospital del Oeste de China. Se recopilaron los datos de indicadores demográficos, clínicos y de pruebas de laboratorio.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">De un total de 48 pacientes, 32 eran de consultas externas y 16 eran pacientes hospitalizados. La edad media era de 51 años, y 30 eran varones. El síntoma inicial más prevalente es la polineuropatía (77,1%). Veintidós de los 48 pacientes tenían un VEGF elevado. La proteína M sérica más prevalente era la IgAλ (54,2%), y un paciente no tenía ninguna proteína M, lo que podría considerarse como el síndrome de POEMS atípico.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Actualmente, el diagnóstico del síndrome de POEMS se basa en la combinación de las manifestaciones clínicas y las pruebas de laboratorio. Enfatizar la pluralidad es de gran importancia para el diagnóstico de esta enfermedad.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total patients (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>48) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Age, y (median, range)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51 (34–74) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Sex</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Serum M protein studies</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>lgA λ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>lgG λ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>lgM λ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>lgA κ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>lgG κ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>lgM κ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>IgA λ and lgM λ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>IgG λ and IgA λ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>None detected \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3637101.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Elevated VEGF \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>22 \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">First symptoms</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Polyneuropathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Skin changes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Organomegaly \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Abdominal distention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Effusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bone pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hyperplasia of mammary glands \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3637102.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Summary of clinical findings of patients with POEMS syndrome.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "POEMS syndrome: definitions and long-term outcome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Dispenzieri" 1 => "R.A. Kyle" 2 => "M.Q. Lacy" 3 => "S.V. Rajkumar" 4 => "T.M. Therneau" 5 => "D.R. Larson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1182/blood-2002-07-2299" "Revista" => array:6 [ "tituloSerie" => "Blood" "fecha" => "2003" "volumen" => "101" "paginaInicial" => "2496" "paginaFinal" => "2506" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12456500" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "POEMS syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A. Dispenzieri" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.blre.2007.07.004" "Revista" => array:6 [ "tituloSerie" => "Blood Rev" "fecha" => "2007" "volumen" => "21" "paginaInicial" => "285" "paginaFinal" => "299" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17850941" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Two cases of special POEMS syndrome without monoclonal protein expression: a case report and literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H.P. Du" 1 => "Y. Zhang" 2 => "L.M. Sun" 3 => "L. Luo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "J Int Med Res" "fecha" => "2021" "volumen" => "49" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Disease associations with monoclonal gammopathy of undetermined significance can only be evaluated using screened cohorts: results from the population-based iStopMM study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.Ý. Sigurbergsdóttir" 1 => "S. Rögnvaldsson" 2 => "S. Thorsteinsdóttir" 3 => "I. Sverrisdóttir" 4 => "G.Á. Sigurðardóttir" 5 => "B. Viðarsson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3324/haematol.2023.283191" "Revista" => array:6 [ "tituloSerie" => "Haematologica" "fecha" => "2023" "volumen" => "108" "paginaInicial" => "3392" "paginaFinal" => "3398" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/37439374" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transient M-proteins: epidemiology causes, and the impact of mass spectrometry: the istopmm study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Palmason" 1 => "O. Berlanga" 2 => "J.K. Sigurdsson" 3 => "S. Rögnvaldsson" 4 => "S. Thorsteinsdottir" 5 => "S. Ekberg" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Blood" "fecha" => "2022" "volumen" => "140" "numero" => "Suppl. 1" "paginaInicial" => "2338" "paginaFinal" => "2340" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00257753/unassign/S0025775324003944/v1_202408300420/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/00257753/unassign/S0025775324003944/v1_202408300420/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775324003944?idApp=UINPBA00004N" ]
