Eruptive ulcerative follicular spicules heralding progression of smouldering multiple myeloma: a case report and a review of the Literature

We describe a patient with IgG-lambda smouldering multiple myeloma with translocation t(4:14) who developed widespread ulcerative horny-like spicules, heralding rapid progression to overt myeloma requiring aggressive chemotherapy and autologous stem cell transplantation. The serum abnormal protein was IgG lambda with chemical-physical properties of cryoglobulin. Histopathologic changes, observed in lesions at different evolutionary stages, evidenced columns of horny-like eosinophilic homogeneous material, immunoreactive for IgG lambda, protruding from the dilated and/or distorted follicular openings or acrosyringia and small vessel thrombotic vasculopathy and vasculitis in concert with an inflammatory neutrophilic and lymphocytic reaction. Biochemical investigations on material from a spicule and ulcero-necrotic lesion revealed cryoprecipitates containing IgG-lambda with electrophoretic characteristics identical to those of the serum dysprotein Follicular hyperkeratotic spicules are a rare, but highly characteristic dermatosis associated with multiple myeloma. To our knowledge, a total of 23 patients - including ours - (18 males, 5 females) have been described. We reviewed the features, the clinical presentations, the involved sites and the temporal relationship with the main disease. . Our findings suggest that the formation of spicules and development of ulcerative lesions are a part of the same clinical spectrum where the cold-dependent precipitation of the immunogenic dysprotein, both in the skin vessels and hair follicle infundibula, play a major pathogenetic role. Whether this highly characteristic paraneoplastic dermatosis can identify patients with high-risk cytogenetic abnormalities and be incorporated into prognostic models, applicable early on in the course of myeloma, warrants further