C40-08 Multiple Myeloma in Patient With Advanced Sarcoidosis: A Dilemma in Management

Introduction The association between sarcoidosis and lymphoproliferative disorders is well-documented. However, data on the coexistence of multiple myeloma (MM) with sarcoidosis remain limited. We present a case of a patient with longstanding sarcoidosis who was subsequently diagnosed with smoldering multiple myeloma. Case Description A 65-year-old female with a 34-year history of pulmonary and cutaneous sarcoidosis, previously treated with corticosteroids, and known pulmonary hypertension, presented with worsening shortness of breath due to a sarcoidosis exacerbation. Her clinical course was complicated by a right lower extremity deep venous thrombosis (DVT). Chest computed tomography (CT) revealed extensive fibrotic changes predominantly in the upper lobes, with traction bronchiectasis and cystic/bullous formations. During outpatient hematology follow-up for DVT, further evaluation for anemia was initiated. Serum immunofixation showed elevated IgG levels at 2930 mg/dL. Bone marrow biopsy revealed 5-7% plasma cells, and 24-hour urine analysis demonstrated a kappa IgG level of 1619 mg/day with a kappa/lambda ratio of 127. Although plasma cell infiltration was below 10%, sampling limitations raised concern, and a diagnosis of smoldering multiple myeloma was made. Methotrexate was initiated for sarcoidosis management but discontinued after seven months due to lack of improvement in the context of fibrocystic lung disease. The patient was transitioned to low-dose prednisone. With ongoing treatment—prednisone for sarcoidosis and sildenafil for pulmonary hypertension—she has remained clinically stable on 2L supplemental oxygen. Lung transplantation is under consideration for definitive management; however, the diagnosis of smoldering MM has precluded active listing. She continues to be monitored closely for disease progression. Discussion Several case reports have described the development of MM in patients with sarcoidosis. While some case-control studies have not demonstrated a statistically significant association between the two conditions, further research with larger sample sizes is warranted. The proposed link involves immune dysregulation in sarcoidosis, which may predispose individuals to MM. However, the association between the pattern of inflammation, which is a granulomatous disorder for sarcoidosis, and the pattern of injury which is a plasma cell disorder in MM, is hard to explain. Current consensus guidelines for lung transplantation consider active malignancy an absolute contraindication, particularly when there is a high risk of recurrence, progression, or mortality. The impact of post-transplant immunosuppression on smoldering MM progression remains unclear. Given the potential association between sarcoidosis and MM, it is essential to better understand this risk to appropriately evaluate sarcoidosis patients for lung transplantation. This abstract is funded by: None