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Abstract
POEMS syndrome is a rare paraneoplastic syndrome due to an underlying plasma cell disorder. The diagnosis of POEMS syndrome can be a challenge. A good history, physical examination, and appropriate testing can aid in establishing its diagnosis. We are presenting the case of a 75-year-old man who was diagnosed with POEMS syndrome.
Keywords: Paraneoplastic syndrome, plasma cell neoplasm, POEMS syndrome, polyneuropathy
How to cite this article: Introduction 
POEMS syndrome, also called Crow–Fukase syndrome, is a paraneoplastic syndrome associated with plasma cell neoplasm. The acronym POEMS stands for Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal Gammopathy, Skin Changes; however, these components are not all required for the diagnosis. It is a rare disease estimated to account for <1% of plasma cell neoplasms.[1]
Case History A 75-year-old, diabetic man presented with anemia and came to clinical pathology with a request for bone marrow examination. Peripheral smear examination showed microcytic hypochromic anemia of a severe degree [Figure 1]. Bone marrow examination revealed 10 to 13% plasma cells [Figure 2]. Concurrently, the patient was also investigated for complaints of polyneuropathy with nerve conduction studies, which revealed bilateral symmetrical sensorimotor axonal polyneuropathy. A skeletal survey showed multiple osteosclerotic bone lesions were found [Figure 3]. On further investigations, his HbA1c and thyroid-stimulating hormone levels were raised. Serum protein electrophoresis showed a suspicious non-discrete protein band in the gamma globulin region (0.3 g/dL) [Figure 4]. Immunofixation electrophoresis identified a very faint non-discrete protein band in the gamma globulin region of IgA and kappa lane corresponding to a possible “M” spike [Figure 5]. Overall, the patient was confirmed to have polyneuropathy, monoclonal plasma cell proliferative disorder, osteosclerotic lesions, and endocrinopathy (diabetes and hypothyroidism). Hence, the diagnosis of POEMS syndrome was made adherent to the World Health Organization (WHO) 2017 criteria for POEMS syndrome [Table 1].
Figure 2: Bone marrow aspiration shows 10 to 13% plasma cells (inset: binucleate plasma cells)
Figure 4: Protein Electrophoresis showed suspicious non-discrete band in gamma globulin region, possibly a monoclonal gammopathy
Figure 5: Immunofixation Electrophoresis identifies a very faint non-discrete protein band in gamma globulin region of IgA and Kappa lane corresponding to ? 'M' spike Discussion The diagnosis of POEMS syndrome is based on a constellation of clinical and laboratory features and it will be missed if not considered. Most notably, the presence of neuropathy along with monoclonal proteins; thrombocytosis; anasarca; papilledema should warrant an in-depth search for POEMS syndrome. The recommended minimum testing to define a baseline and for future assessments was proposed by Dispenziari.[2]
Distinguishing POEMS syndrome from other differential diagnoses is necessary because the treatment and expected treatment-related morbidities are quite different. If a patient with POEMS syndrome is incorrectly deemed to have MGUS (monoclonal gammopathy of undetermined significance) or smoldering myeloma, the monoclonal plasma cells will not be targeted by the therapy. This will result in worsening of existing symptoms and accumulation of further elements of the paraneoplastic syndrome. In contrast, if a patient with POEMS syndrome is incorrectly labeled as plasma cell myeloma or plasmacytoma, the standard therapy for these disorders results in increased treatment-related morbidity.
Other differential diagnoses include chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), Waldenstrom's macroglobulinemia, immunoglobulin light chain amyloidosis, chronic ataxic neuropathy with ophthalmoplegia (CANOMAD), M-protein, cold agglutinins, and anti-disialosyl antibodies).[3]
The etiology and pathogenesis of POEMS syndrome are not well understood; however, markedly elevated levels of vascular endothelial growth factor (VEGF) appear to be an important pathogenic factor. Helpful cut-offs for plasma and serum VEGF levels to diagnose POEMS syndrome are 200 pg/mL (specificity 95%, sensitivity 68%).[4]
Wang et al.[5] have identified N-terminal propeptide of type I collagen (P1NP) as a novel marker for the diagnosis and follow-up of patients with POEMS. P1NP is the cleavage product of type 1 collagen, which constitutes 90% of the bone protein. It is a newly emergent marker of bone formation and has shown its clinical value in detecting osteosclerotic metastases. It has also proved to be a useful marker in standardizing the evaluation of osteosclerotic lesions in POEMS syndrome with a specificity of 91.5% and a sensitivity of 80%.
In most cases, POEMS syndrome is a chronic and progressive disease with a 5-year survival rate of 60 to 94%. Several clinical factors are associated with shorter survival, including extravascular fluid overload, clubbing, and respiratory symptoms.
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Conflicts of interest
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References 
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CheckDOI: 10.4103/ijpm.ijpm_857_21
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