A 65-year-old man presented with a 2-year history of progressive hair loss involving the scalp, the eyebrows and the upper trunk, and recent onset of small papules and blisters on the dorsal hands as well as longitudinal ridging and fissuring of the fingernails. Clinical examination showed diffuse alopecia most pronounced on the androgen dependent scalp; the skin was slightly indurated on palpation []. There were focal petechiae. The lateral sides of both eyebrows and most of the hair on the chest were absent too. The axillary, pubic, and limb hair was preserved.\nTrichoscopic examination of the scalp showed prominent salmon colored halos (0.3-1 mm in diameter) surrounding the follicular ostia []. These halos were seen around empty follicles as well as around follicles containing terminal and vellus hairs, black dots, and/or broken hairs. This trichoscopic finding was present over the entire scalp.\nA 4 mm punch biopsy from the alopecic scalp was obtained and bisected in horizontal sections. There was overall preserved follicular architecture with intact sebaceous glands []. There were no terminal anagen follicles, one terminal telogen follicles, two vellus anagen follicles and 10 atrophic follicular structures reminiscent of telogen germinal units (secondary germs). All follicular structures were surrounded by amorphous eosinophilic material, which formed either a compact- or loosely- folded fibrillar cast []. The same material was deposited in all fibrous streamers, which appeared eosinophilic, homogenized and avascular. Congo red stain evaluated under polarized light highlighted the apple green stain of the amyloid [].\nSerum electrophoresis and bone marrow biopsy established the diagnosis of multiple myeloma.
A 60-year-old man presented with a history of lower back pain that had persisted for 2 years and difficulty walking for 2 months. The patient received a complete hemogram as well as routine biochemical and radiographic imaging studies. His hemoglobin level was 15.3 g/dL, his total leukocyte count was 6.1×109/L, his platelet count was 160×109/L, and his erythrocyte sedimentation rate (ESR) was 15 mm. No rouleaux formation was seen on a peripheral smear. Serum blood urea nitrogen (27 mg/dL), creatinine (1.06 mg/dL), calcium (9.9 mg/dL), and albumin (5.1 g/dL) were all within normal limits. Serum uric acid levels were high (7.6 mg/dL), Alkaline phosphatase levels were slightly increased (134 U/L), and the patient had subnormal vitamin D3 levels. Ultrasonography findings were within normal limits, except for mild prostatomegaly. Serum prostate specific antigen and carcinoembryogenic antigen levels were within normal limits.\nA radiograph of the dorsolumbar spine showed diffuse osteoporosis and wedging of the D12 vertebra. Multiple small permeative lesions were seen in the pelvic bones and proximal femoral shafts. MRI findings showed diffuse degenerative changes in the cervical and lumbar spine and D12 vertebral collapse. Bone scan showed increased uptake in the anterior region of the 6th rib, left sacroiliac joint, and occipital region. Serum protein electrophoresis did not show any M spike, and gamma globulin levels were normal (8.8 g/L). Urine protein electrophoresis showed protein levels of less than 60 mg/L and no M spike. The bone scan findings, together with increased serum uric acid and alkaline phosphatase levels, and negative myeloma workup suggested possible diffuse skeletal metastasis. The patient underwent bone marrow aspiration from the bilateral posterior iliac spines and unilateral trephine biopsy to look for any secondary causes of bone scan findings and to rule out the presence of a plasma cell neoplasm. The aspirates from both sides showed similar findings, with numerous plasma cells ranging from 60–70% (). Binucleated or multinucleated forms, plasmablasts, and occasional mitotic figures were also observed in those plasma cells. Additionally, intranuclear Dutcher bodies and occasional Mott cells were observed. The Congo red stain for amyloid on the trephine biopsy was negative. IHC was performed on the trephine biopsy, revealing cells positive for CD138, MUM 1, and cytoplasmic κ and negative for CD3, CD20, LCA, CD56, and lambda (λ). The Ki-67 labelling index was 15%. The mean λ FLC level was 11.2 mg/L (range, 5.5–26.3 mg/L), and that of κ was 176.8 mg/L (range, 3.3–19.4 mg/L). The mean κ/λ ratio was 15.78 (range, 0.2–1.65). Patient had high β2-microglobin levels, at 2,557 mg/mL (range, 609–2,366 mg/mL).\nThe patient was in clinical stage I according to the International Staging System (ISS) for plasma cell myeloma and stage IIIA according to the Durie-Salmon staging system. The patient was referred to the oncology center for further management. There the patient was treated with a chemotherapy regimen that included the proteasome inhibitor bortezomib and dexamethasone.