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Título

Central nervous system infiltration on multiple myeloma: two case reports of a rare clinical presentation

RESUMO

Case report
Case 1
A 64 years old patient presented to the emergency department complaining of holocranial headache, unsteady gait and drowsiness. She had a history of multiple myeloma inactive for four years after an autologous stem cell transplantation presented to the emergency department. Her neurological examination showed proximal muscle weakness associated with exacerbation of all tendinous reflexes, demanding us to a complementary investigation with cranial neuroimage.
The magnetic resonance imaging showed leptomeningeal, ependymal, supra and infratentorial lesions with involvement of cranial nerves (subclinical at the moment) and parenchymal micronodular lesions. There were also lesions in the cervical level of the spinal cord associated with diffuse leptomeningeal impregnation, affecting the cervical, thoracic, lumbar regions and the cauda equina roots. The lumbar puncture showed monoclonal plasmocytes.
Rescue chemotherapy was attempted, without therapeutic response. She died 5 months after the recurrence.
Case 2
A 58-year-old female patient diagnosed with multiple myeloma for 4 years since admission, with previous autologous bone marrow transplant presented to the hospital with vertigo and headache.
The magnetic resonance imaging showed lytic lesions on parietal bones with intense gadolinium uptake associated with significant temporal leptomeningeal thickening, inferring invasion of the central nervous system by the underlying disease. The initial cerebrospinal fluid puncture had 27 cells, 100% with neoplasic features. Rescue chemotherapy was performed, however the patient died 5 months after diagnosis.
Discussion
Multiple myeloma is a hematological disorder caused by abnormal plasmocyte clones with production of monoclonal antibodies. The disease can cause some neurological symptoms secondary to peripheral nervous system disease, amyloidosis and spinal cord accometiment. However, while some oncological diseases more commonly presents with brain metastasis or leptomeningeal invasion, these are rare on myeloma multiple patients. Invasion of the central nervous system by multiple myeloma denotes a poor prognosis, with some studies demonstrating an average survival of 3 months, similar to the patients presented in this case.
Final Comments
These case are rare and severe presentations of multiple myeloma. Knowledge of such manifestations and detailed investigation allows an accurate management.

Palavras Chave

Multiple myeloma, metastatis, central nervous system