MM may manifest with kidney failure, anemia, hypercalcemia, lytic bone lesions, pathologic fractures, immunodeficiency, and hyperviscosity. MM can also affect the adrenal glands, lungs, liver, spleen, pancreas, lymph nodes, and skin.3,4,6–8
Cutaneous plasmacytomas are extremely rare, specific cutaneous findings of MM. They occur late in the course of the disease and present as erythematous nodules and plaques. They can present initially with common and nonspecific cutaneous lesions such as leukocytoclastic vasculitis, amyloidosis, pyoderma gangrenosum, or vesiculobullous disorder; it is difficult to suspect MM with the initial presentation of skin lesions mentioned above.1,9,10
AL amyloidosis may occur as an idiopathic condition or be associated with MM or lymphoma.2 Skin infiltration with amyloid leads to the formation of papules, nodules, or plaques.6 Hemorrhagic skin findings (petechia, purpura, and ecchymosis) are seen frequently on the eyelids, neck, axillae, and anogenital areas due to the amyloid infiltration of the vessel walls following a minor trauma such as amyloid purpura or pinch purpura.6,7 During coughing, the Valsalva maneuver, or proctoscopy, the signs and symptoms listed above can occur and are seen most commonly on the flexural regions, such as the eyelids and inframammary regions.6 There are some studies on severe skin or internal bleeding due to coagulation factor inhibitory circulating paraprotein, hyperfibrinolysis, platelet dysfunction, or isolated acquired factor X deficiency in amyloidosis; however, to the authors’ knowledge, skin avulsion due to minor traumas has not been reported in the literature.11,12
Corneal abrasions (CAs) are the most common corneal complications during general anesthesia, and their incidence varies between 0% and 44% depending on the method used for eye protection.13 For CA prophylaxis in the perioperative period, it is recommended to ensure eyelid closure by securing the eyelids with tape; applying lubricating eye ointment is recommended when this is not feasible.13–15 In the authors’ hospital, anesthesiologists prefer to use the tape method in the majority of patients to prevent perioperative CAs, as some studies report negative side effects of lubrication, such as blurred vision and ocular edema.16–18 In the current case, during the removal of protective tape the authors encountered skin avulsion of the right eyelid skin. No reports of this complication could be found in the authors’ review of the literature.
Medical adhesives are an integral part of health care delivery and are a component of a variety of products such as tapes and dressings. Medical adhesive-related skin injury (MARSI)19 has a significant, negative impact on patient safety as seen in the current case. The skin injury encountered on the right eyelid can be considered a serious example of MARSI.
The diagnosis of AL amyloidosis in MM is made by both clinical findings and histopathologic study. On histopathologic examination, lesions reveal eosinophilic amorphous material accumulation in the dermis and subcutaneous tissue as well as in the areas surrounding veins and sweat glands. When biopsy material is stained with Congo red, the finding of green birefringence with a polarized light microscope confirms amyloidosis.8 Histologic evaluation of the current case revealed that AL amyloidosis developed during the course of MM recurrence.
The second biopsy specimen taken from the patient was compared with the first biopsy specimen by using a high-resolution DS-Ri1 color camera and NIS-Elements imaging software (Nikon, Tokyo, Japan). Although amyloid deposition was diffusely seen in a great part of the tissue in the second biopsy specimen, the deposition was noted only in a limited area in the first (Figure 2A and Figure 2B). Increased amyloid deposition over time explains the clinical symptoms that have evolved from minor bruising to skin damage by minor traumatic events, as in the example the authors encountered on the current patient’s left eyelid.