Letter to the Editor
Jejunal extramedullary plasmacytoma
Plasmocitoma extramedular de localización en yeyuno
Antonio Rosales-Castillo
, Antonio Bustos-Merlo
Corresponding author
Servicio de Medicina Interna, Hospital Universitario Virgen de las Nieves, Granada, Spain
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He consulted our clinic for a two-month history of intense asthenia, hyporexia, and a weight loss of 10 kg associated with intermittent heart burn and bilious vomiting, as well as melenic stools, but no alterations in his intestinal rhythm. A physical examination revealed significant cachexia, muscle weakness, and sinus tachycardia, but no remarkable findings in the abdominal examination. No traces of melenas were detected during a rectal examination. The most remarkable findings of the laboratory tests were increased urea levels (247 mg/dl), as well as a worsening in his creatinine levels (2.55 mg/dl), hypokalemic (3.10 mEq/l) and hypochloremic (77 mEq/l) metabolic alkalosis, and normochromic normocytic anemia (hemoglobin levels of 6.9 g/dl and mean corpuscular volume of 82 fl). An abdominal X-ray revealed no signs of dilatation of the intestinal loops. After receiving several transfusions of packed red blood cells, the patient was admitted to the clinic to undergo ancillary testing. Because an anemia screening study showed an iron profile with an increased reticulocyte index, an upper and lower digestive endoscopy were performed, detecting a hiatal hernia and colon diverticulosis, respectively. This study was completed with a capsule endoscopy that revealed no bleeding lesions. The protein and immunoglobulins panels revealed normal findings, except for slightly decreased immunoglobulin G (IgG) levels (358 mg/dl) that had already been present previously, and beta-2-microglobulin levels of 5.19 mg/dl, similar to the previous study. Serum and urine electrophoresis tests ruled out a monoclonal component and a bone marrow puncture yielded a hypercellular aspirate with 0.2% plasma cells. Positron emission tomography (PET)/computed tomography (CT) imaging tests showed a hypermetabolic mass in his small bowel, at the level of the right flank, with high metabolic activity (standardized uptake value [SUV] of 11.3).</p><p id="par0020" class="elsevierStylePara elsevierViewall">Given the patient’s significant clinical deterioration, his case was presented in a meeting held with the General Surgery committee, during which it was jointly agreed to perform a surgical intervention considering the suspected existence of an intestinal neoplasm. During this procedure, a stenosing tumor was detected in the jejunum, at approximately 20 cm from the duodenojejunal flexure and associated with jejuno-jejunal invagination. The tumor was resected and sent for pathological testing, which yielded a diagnosis of a plasma cell neoplasm of mature appearance, with Dutcher bodies, positivity for CD138, CD38, MUM1, and CD79a, and expression of lambda light chains compatible with a plasmacytoma at said level.</p><p id="par0025" class="elsevierStylePara elsevierViewall">After conducting the surgical procedure and reaching the diagnosis, treatment with daratumumab was started, achieving progressive clinical improvement.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Extramedullary plasmacytoma represents 3%–5% of all plasma cell neoplasms<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and its treatment varies depending on whether it appears isolated, in which case local treatment in the form of focused radiotherapy and/or surgical resection is preferred, or associated with multiple myeloma, in which case systemic treatment is usually also administered. The prognosis of the condition also varies, being more favorable in isolated cases compared with those associated with multiple myeloma. Although the appearance of a plasmacytoma in the gastrointestinal tract during the course of a multiple myeloma is already quite rare (0.9%), it is even rarer in the small intestine, with very few cases of this type of involvement being reported in the medical literature.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Its clinical presentation depends on both the affected organ and the degree of invasion, from incidental asymptomatic forms to digestive hemorrhages, chronic anemia, refractory abdominal pain, ascites, or intestinal occlusion secondary to a mass effect.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Although there is no standardized treatment for these cases, the addition of chemotherapy to the local surgery and radiotherapy, together with the possibility of performing an autologous stem cell transplantation, increases the chances of remission and survival compared with the application of local treatment alone.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rosales-Castillo A, Bustos-Merlo A. Plasmocitoma extramedular de localización en yeyuno. Med Clin (Barc). 2021;157:305–306.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Plasmacytoma as a cause of small bowel obstruction in a virgin abdomen in a patient with multiple myeloma: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.A. Mwinyogle" 1 => "A. Bhatt" 2 => "K. Kapisoda" 3 => "J. Somerville" 4 => "S.C. 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