Metastatic pulmonary calcinosis and leukocytoclastic vasculitis in a patient with multiple myeloma.

"DISCUSSION: The presented patient presented with severe dyspnea and ulceronecrotic skin lesions, and was diagnosed as multiple myeloma. A skin biopsy specimen obtained from ulceronecrotic lesions showed leukocytoclastic vasculitis and HRCT of the lungs showed metastatic pulmonary calcification. To the best of our knowledge this is the first case reported with these 3 findings. After 3 courses of standard first-line multiple myeloma chemotherapy, the patient achieved partial remission, and all skin and pulmonary lesions disappeared. : Leukocytoclastic vasculitis is a paraneoplastic syndrome, which is observed most commonly in cases of hematological malignancy, such as lymphoid neoplasm or myelodysplastic syndrome [4,6]. Leukocytoclastic vasculitis rarely occurs during the course of multiple myeloma [2]. This vasculitis is an inflammatory necrotizing condition of the superficial dermal vessels, and is characterized by neutrophilic, angiocentric, segmental inflammation with endothelial cell injury and fibrinoid necrosis of the blood vessel walls [9]. Clinical symptoms are variable and include palpable purpura, and hemorrhagic-necrotizing, bullous, nodular, and urticarial lesions [10]. : Sanchez et al. [2] reported a case of multiple myeloma associated with paraneoplastic vasculitis and reviewed 8 other reported patients. In all, 6 of the 9 patients were diagnosed as type IgA myeloma. All the patients had palpable purpura involving the legs and/or trunk, and 2 patients had ulceronecrotic lesions, as in the presented case. Skin lesions in 6 of the patients improved after treatment of multiple myeloma. Bayer-Garner et al. reported 8 patients with multiple myeloma that developed leukocytoclastic vasculitis [11]. They reported that 4 of the patients were diagnosed as IgG myeloma with diffuse skin lesions, as was the presented case. : Metastatic pulmonary calcification generally occurs in patients with hypercalcemia [12]; multiple myeloma is less commonly a cause of metastatic pulmonary calcification. Generally, patients with metastatic pulmonary calcification are asymptomatic, but restrictive lung function, decreased diffusing capacity, hypoxemia, and respiratory failure may occur [12]. Plain radiography of the chest is usually normal. HRCT generally shows centrilobular ground glass nodular opacities. In cases of metastatic calcification calcium deposits may accumulate to such tissues as lung, stomach, skin, and kidney [13,14]. Weber et al. reported a multiple myeloma patient with metastatic pulmonary calcification. After treatment of multiple myeloma, pulmonary infiltration decreased, as in the presented case [15]. Marchiori et al. [12] reported 3 patients who presented with metastatic pulmonary calcification with unusual HRCT findings, 1 of which died due to diffuse metastatic calcification in the parenchyma of major organs, including the heart, lungs, kidneys, meninges, and skin, and was diagnosed as multiple myeloma during autopsy. Another study reported 4 cases diagnosed as paraneoplastic hypercalcemia with metastatic calcification, based on autopsy, 1 of which presented with paraneoplastic hypercalcemia and was diagnosed as multiple myeloma [16]. Most of the reported cases of metastatic calcinosis died early because of acute pulmonary failure or because the underlying disease was refractory to treatment; even though symptoms resolved following treatment, they died due to disease progression. : In conclusion, both leukocytoclastic vasculitis and metastatic pulmonary calcification are conditions that rarely occur during the course of multiple myeloma. Treatment of multiple myeloma may improve skin lesions and metastatic calcification, but the prognosis appears to be poor despite administration of the most effective treatments. : Conflict of Interest Statement: The authors of this paper have no conflicts of interest, including specific financial interests, relationships, and/ or affiliations relevant to the subject matter or materials included."