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Patient: Female, 76-year-old
Final Diagnosis: Multiple myeloma
Symptoms: Bullous skin lesions &#; leg edema &#; leg ulcers &#; pain &#; paresthesia of extremities &#; purpuric pigmentations &#; purpuric skin lesions
Clinical Procedure: Analgesia &#; corticosteroids &#; dressing &#; laser therapy
Specialty: Dermatology &#; Hematology &#; Pathology &#; Surgery
Unusual clinical course
Leukocytoclastic vasculitis (LCV) is an atypical form of cutaneous paraneoplastic manifestation. Its association with multiple myeloma (MM) is even rarer and is associated with poor prognosis and short survival, regardless of the therapy instituted. Different treatment approaches are necessary. We present a case in which LCV was the first manifestation of MM, and high-intensity laser therapy (HILT) was used as an option to accelerate healing and control pain.
A 76-year-old woman presented with pain and paresthesia in her lower limbs, associated with palpable purpura. The clinical diagnosis was small-vessel vasculitis. Laboratory tests showed an elevated gamma globulin monoclonal peak on protein electrophoresis. The immunophenotypic study of bone marrow aspirates led to the diagnosis of MM. Due to pain refractory to conventional analgesics, and the progressive evolution of the lesions, despite corticosteroid therapy, we performed photo-biomodulation with a neodymium-doped yttrium aluminum garnet laser (Nd: YAG), wavelength nanometers, using a 7-mm probe and energy density 6 J/cm2. After the first session, the patient was referred for pain management, and after 5 weeks, we observed complete healing in ulcerated lesions and involution of bullous lesions.
This case report shows the positive effects of the Nd: YAG laser in modulating healing and reducing pain. HILT is an innovative, non-invasive, and effective treatment and should be considered a promising technique to accelerate healing and controlling pain.
Keywords:
Laser Therapy, Multiple Myeloma, Paraneoplastic Syndromes, Vasculitis, Wound Healing
Cutaneous leukocytoclastic vasculitis (LCV) is a systemic inflammatory disorder involving the small vessels. It is characterized by segmental angiocentric neutrophilic inflammation, endothelial damage, and fibrinoid necrosis. LCV can clinically present in various forms, from urticarial macules to ulcerated and necrotic lesions [1,2]. Paraneoplastic vasculitis (induced by lymphoproliferative disease, myeloproliferative disease, or carcinoma) represents less than 5% of all cases of LCV [3]. The association with multiple myeloma (MM) is rare, and only 22 such cases have been reported in the literature [4].
Unfortunately, the management of paraneoplastic vasculitis is not standardized and has been associated with the treatment of underlying disease. Antihistamine drugs, non-steroidal anti-inflammatory drugs, corticosteroids, or immunosuppressants can be used [5,6].
Laser therapy has been used as an alternative to reduce pain and accelerate wound healing [7]. It is a non-invasive and painless physiotherapy modality consisting of low-level light therapy (LLLT) with energy output <500 mW, reaching only superficial tissues, and high-intensity laser therapy (HILT) with energy output >500 mW and can reach deeper tissues [7]. Some protocols with neodymium-doped yttrium aluminum garnet laser (Nd: YAG), wavelength nanometers, are considered HILT and have photo-biomodulation and anti-inflammatory effects [8].
This report is of a case in which cutaneous vasculitis had encouraged investigation for an underlying disease and determined the diagnosis of MM. HILT with Nd: YAG laser was performed to promote photo-biomodulation, accelerate inflammatory absorption, increase collagen synthesis and tensile strength, shorten wound healing time, reduce wound size [8], and control pain patterns [9].
A 76-year-old woman presented with palpable purpura and painful ulcers 2 weeks before coming to our institution. The clinical signs were associated with asthenia, swelling, burning pain, dyskinesias, and paresthesia in the lower limbs 2 months before the cutaneous manifestation. She had no history of arterial or venous disease, only primary arterial hypertension. There was no history of previous neoplasia or similar clinical picture. On physical examination, the patient had palpable pulses in all limbs, and no varicose veins were detected. There was mild distal edema of the legs, palpable purpura, some coalescent, disseminated throughout the infragenicular region and feet, bilaterally (). Two ulcerated lesions with irregular necrotic edges, approximately 1.5×2.0 cm and 0.5×0.5 cm in diameter, respectively, with inflammatory signs, were observed on the medial side of the ankle. Other scattered blistered and blackened lesions were also present. These lesions are uncommon in chronic venous insufficiency (CVI) and suggest vasculitis (). The patient had no lymphadenopathy.
Open in a separate windowOpen in a separate windowThe diagnostic hypothesis was small-vessel vasculitis. Histopathological analysis of a skin lesion revealed vascular degeneration, mixed angiocentric infiltration containing lymphocytes, histiocytes, and neutrophils, mild red blood cell extravasation, and fibrinoid necrosis in vessel walls, indicating leukocytoclastic vasculitis ().
Open in a separate windowHence, additional tests were performed. The duplex scan eliminated CVI and peripheral arterial disease. Viral involvement or association with rheumatological disease was ruled out. Laboratory tests detected an increase in erythrocyte sedimentation rate and C-reactive protein, beta 2 microglobulin: 3.98 mcg/mL (reference range (RR): 1.09 to 2.53 mcg/mL) and a monoclonal gamma peak globulin in protein electrophoresis (2.402 g/dL, RR: absent). Serum IgG levels were slightly elevated at .0 mg/dL (RR: 650 to mg/dL). Immunofixation of urinary proteins demonstrated the presence of a monoclonal IgG/Kappa component. Immunofixation electrophoresis detected a monoclonal IgG/kappa component and free light chain analysis was performed, showing a kappa chain level of 26.10 mg/L, a lambda chain level of 11.0 mg/L, and a kappa/lambda ratio of 2.373 (VR: 0.31 to 1.56), indicating kappa gammopathy ().
Culturing of a specimen showed a positive result for Citrobacter freundii sensitive to ciprofloxacin, which was initiated at a dose of 500 mg twice a day, associated to oral corticosteroid therapy with 40 mg of prednisone once a day. The nursing team made the dressings with foam plates, which is a type A recommendation for painful ulcers [10].
The hematology team performed bone marrow puncture, which showed plasmacytosis on the myelogram. A bone marrow anatomopathological study showed hypercellularity due to atypical plasmocytosis (). The immunophenotypic assessment of bone marrow aspirate showed 0.32% of abnormal immunophenotypic plasmocytes expressing monoclonal kappa light chain (cytoplasmic). Immunohistochemical findings corroborated the diagnosis of MM CD138+ with kappa light chain expression (). Non-specific chemo-therapy was chosen because the MM stage did not fulfill the criteria for transplantation or chemotherapy.
Open in a separate windowDue to pain refractory to conventional analgesics and the progressive evolution of lesions despite oral corticosteroid therapy, HILT photo-biomodulation was initiated. The parameters used were: nanometers wavelength laser, micro-pulses of 300 microseconds duration, a 7-mm probe, and energy density 6 J/cm2. The exposure time and amount of energy supplied were calculated by the formula: Power=Energy/Time. A thermography camera was used as a safety measure to avoid application errors or burns. Laser therapy sessions were performed twice a week. A healing rate of 0.53, approximately 7 mm2 per day, was achieved in ulcerated lesions and involution of bullous lesions after 10 sessions in 5 weeks.
There was considerable improvement in the pain pattern and edema of the lower limbs after control of cutaneous vasculitis. The skin still presents post-inflammatory hyperchromic macules without atrophic or dystrophic scars (). After the lesions healed, the dose of prednisone was gradually reduced until complete suspension. Eight months later, new lesions appeared, and the same treatment was successfully instituted. Currently, the treatment with corticosteroids continues, with a daily oral dose of 5 mg of prednisone, and the patient remains asymptomatic in hematological follow-up without chemotherapy treatment or bone marrow transplant.
Open in a separate windowThe association between LCV and MM is rarely observed. LCV is related to lymphoproliferative diseases in only 1% of cases [3,4]. Its development has been linked to cryoglobulinemia, infections, and hypersensitivity to drugs, and rarely presents as paraneoplastic syndrome [11].
The possible mechanisms responsible for developing vasculitis include abnormal production of immunoglobulins in response to abnormal tumor cells and vascular antigens of the endothelium, forming either in situ immune complexes or circulating immune complexes that deposit on the vessel walls. Impaired clearance of typically produced immune complexes is also postulated [11,12].
LCV may manifest before the diagnosis of malignancy, be concomitant, or indicate a recurrence. In some patients, it precedes the emergence of clinical manifestations of neoplasia by 2&#;4 years [2,4].
Only 22 cases associating MM and vasculitis have been reported [4,13&#;24]. In a review conducted at the Myeloma Institute of the University of Arkansas between January and July , 8 cases of LCV associated with MM were found among patients. LCV may be diagnosed simultaneously with MM or preceded other signs and symptoms of multiple myeloma by a few years. In this case, it preceded MM by several weeks. The predominance of IgG paraprotein was observed in 60% of cases and IgA in 20&#;25% [4]. The reported case is also related to the monoclonal component of IgG/kappa, as in most of the 22 reported cases in the literature [2,4,11,14&#;25] (). In addition, the prognosis was favorable, and lesions healed after the institution of appropriate treatment: chemotherapy in 10 cases and 1 case after bone marrow transplant [2,4,11,14&#;25]. Two patients died before recovering, and there were no references in 9 cases [4,14,20].
Therefore, the prognosis of vasculitis relies on the evolution and treatment of the underlying disease [5,6]. In the reported case, non-specific chemotherapy was chosen because the patient did not have anemia, hyperkalemia, bone lesions, kidney damage, or hyperviscosity and did not fulfill the criteria for transplantation or chemotherapy. Oral corticosteroids alone were not effective in healing the skin lesions. Therefore, HILT was an alternative to accelerate the tissue healing process, control pain, and assist the action of corticosteroid therapy. The Brazilian Society of Dermatology has published the Brazilian consensus on the diagnosis and management of chronic leg ulcers in and considers laser therapy to be a promising treatment [26].
The primary biological effects of laser therapy on biological systems include mechanical, electrical, thermal, photochemical, and bio-stimulating effects [27]. Laser therapy with the wavelength of nm provides the best penetration into tissues, and its absorption by some tissue chromophores (such as hemoglobin, melanin, and water) is lower, thereby avoiding creation of thermal lesions and enhancing the wound-healing process [27&#;29].
A cascade of metabolic effects results in several physiological changes, causing better tissue repair, faster resolution of the inflammatory response, and reduced pain [30]. The -nm laser wavelength delivers a specific dose of energy to the areas of the tissue to be treated, providing photo-biomodulation at the cellular level by inducing endogenous ATP synthesis and increasing oxygen consumption, the activity of membrane enzymes, and the synthesis of DNA and RNA [31,32]. At the tissue level, there is a decrease in inflammatory mediators by the activation of lymphocytes and macrophages secretion of fibro-blast growth factors, in addition to fibrin reabsorption, collagen remodeling, neoangiogenesis, and vasodilation [28,29,33].
Some reports have found HILT to have anti-inflammatory and analgesic effects in patients with musculoskeletal disorders by slowing the transmission of pain stimuli and increasing the production of morphine-mimetic substances [9,34]. In the literature, the analgesic effect of HILT is described as immediate and long-lasting, as it was in our case [35].
Notably, some studies have demonstrated the effectiveness of HILT in accelerating wound healing [8,27,28,30,31,34,36]. Nd: YAG laser irradiation effectively inhibits the growth of Staphylococcus aureus and Pseudomonas aeruginosa in microbiology laboratory samples, proving that laser therapy can eradicate pathogens by inducing alteration in DNA [36].
An experimental study by Mahran compared the effects of high- and low-intensity lasers on the healing of acute wounds induced on the back of diabetic rats. Histological analysis indicated that epithelialization was faster in those undergoing laser therapy vs the control group and that there was no difference between the groups treated with LLLT and HILT [28].
In , Alayat&#;s meta-analysis included 122 patients. It concluded that a high-intensity laser is a safe and effective alternative in the healing of neuropathic ulcers, reducing the size of lesions and reducing their closing time [30].
As in prior studies, the present case demonstrated that HILT accelerated wound healing time and reduced pain patterns.
This case demonstrates that leukocytoclastic vasculitis can precede other signs and symptoms of multiple myeloma and should alert clinicians to the possibility of this diagnosis. HILT can be a painless, safe, and effective alternative treatment of vasculitis. The disadvantages of HILT include the cost and the need for technical knowledge to prevent undesirable effects such as burns. Nonetheless, further cost-benefit studies are necessary to validate HILT protocols with Nd: YAG for these purposes.
Publisher&#;s note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher
Declaration of Figures&#; Authenticity
All figures submitted have been created by the authors who confirm that the images are original with no duplication and have not been previously published in whole or in part.
HNC Low Level Cold Laser Therapy Device 650nm and 808nm used in Physiotherapy and Rehabilitation
General Introduction
HNC Multi-functional combines 650nm and 808nm cold laser. Cold laser is also called low power laser, low level laser or soft laser, which outputs power density at 1 j/cm2 level. Some practitioners of acupuncture have suggested that cold laser therapy could be used much like acupuncture and acupressure, with the beams of the laser targeting specific points on the body, since the stimulation of pressure points can be used to treat a number of conditions treatable with acupuncture. After the cold laser is applied to biology, there is no irreversible damage to biological organization, but just a series of physiological and biochemical Changes are caused.
Detailed parts
Function
Specification
ltem
Description
Laser medium
GaAlAs Semiconductor
Laser wavelength
650nm,808nm
Laser output power
5mW for 650nm laser 180mW for 808nm laser
Environment temperature range
40-55&#;
Relative humidity
10%-100%
Atmospheric pressure
86kpa-106kpa
Probe A
11 laser beams are 650nm red laser: 4 laser beams are 808nm invisible laser output power: 775mW
Probe B
808nm invisible laser beam, output power: 180mW
Laser penetration
3~5cm
Output frequency under Pulse mode
0.5sec
Size
310×250×180mm
.Application Range: headache, veterinary, regeneration of muscle fiber, cardiovascular and cerebrovascular diseases ,soft tissue wounds, trauma, skin and mucosal ulcers, pain relief, arthritis, inflammation ,fracture healing, rhinitis, veterinary, regeneration of muscle fiber, cardiovascular and cerebrovascular diseases, hyperviscosity, hyperlipidemia, dysfunction, rheumatism and dermatosis.
FAQ about Cold Laser
What is cold laser therapy?
Cold laser therapy also known as low level laser is non-invasive, safe and effective treatment. Laser light is used to reduce pain, promote healing and soft tissue repair. Within a specific wavelength of light, bio-stimulation can be achieved.
How does it work?
Laser light releases photons to cells. Cells utilize photons to produce an energy molecule known as ATP. ATP is needed by cells to perform various tasks in the body. Therefore, laser light energizes cells to result in a faster healing rate.
How is it administered?
Treatment is usually done with a laser device placed a few cm away from the body. No pain is perceived by the treatment. Sometimes a tingling sensation can be perceived by some patients. It is needed to prevent strays of light from the laser entering the eyes.
Is it safe?
There are no side effects with laser therapy. The reaction that takes places sometimes is a pain reaction from an enhanced immunological response, but subsides after 24-48 hours.
How to Use HNC Multi-functional?
The daily accumulative time of treatment (any probe) shall not exceed 40 minutes. The aged or sensitive patients should begin from the low-power and short-time treatment. The power and time could be increased gradually when the body adapts to the machine. Use the machine once or twice a day and 30 minutes for each time.
Features of HNC Multi-functional
1. Painless, non-invasive, green and safe physical therapy.
2. Perfect combination of 808nm laser and 650nm laser.
3. Adjustable laser output power and time.
4. Creative systemic treatment on large surfaces, joints and acupoints.
5. Compact and portable for convenient use.
S.NO. NAME OF THE DISEASE TIME OUTPUT POWER
1. CERVICAL SPONDYLOSIS 20 min. 300 mw
2. TENNIS ELBOW 10min 400mw
3. OSTEOARTHRITIS 20 min 400mw
4. MUSCULAR PAIN 10 min 300mw
5. WOUND HEALING 10 min 200mw
6. NERVE REGENERATION 20 min 300mw
7. SOFT TISSUE INJURY 10 min 400mw
8. SKIN TREATMENT 10 min 100mw
9. CHRONIC DEGENERATIVE DISEASE 20 min 400mw
10. FROZEN SHOULDER 20 min. 300mw
11. GOLFERS ELBOW 10min 400mw
12. LUMBAGO 20 min 400mw
13. LUMBAR SPONDYLOSIS 20min 400mw
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14. TRIGEMINAL NEURALGIA 10 min 200mw
15. ANKLE DISTORTION 10 min 300mw
16. SCIATICA 20 min 500mw
17. FACIAL PARALYSIS 10min 200mw
18. ROTATOR CUFF TEAR 20min 500mw
19. CERVICAL RADICULOPATHY 10min 500mw
What conditions can be treated with the portable Laser?
Laser therapy can be used in any area of the body, for this reason it can be used for treating conditions such as:
General pain
Back and neck pain
Inflammation joint pain
Sciatic pain
Shoulder pain
Arthritic pain
Fibromyalgia
Tendinitis
Muscle strains or sprains
Compression fractures
Sports injuries
Foot ulcers (common in diabetics)
Product Description
Laser classification
GaAIAs Semiconductor
Laser wavelength
808nm and 650 nm
Output power of probe A
1 laser diodes with 808nm
Output power of probe B
11 laser beams with 650nm and 4 laser beams with 808nm
Maximum power output
Probe A is 180mW and Probe B is 775mW
Time setting
10-60 minutes and 6 grades adjustable
Working temperature
-40-55°C
Relative humidity
below 80%
Atmospheric pressure
86kpa-106kpa
Dimension(cm)
product
34*24*16
package
36.2*25.4*30.2
Weight(KGS)
3.5kg
Indications
Chronic pain like knee arthritis
frozen shoulder
Acute pain like joint issues
athletic system injury
Anti-inflammations
wound healing and laser acupuncture
Five Characteristics
5 Characteristics
High Definition Screen
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Dual Metal Probes
>> Perfect combination of medical laser 808nm and home laser 650nm
Time Setting
>> Time setting10-60 minutes and 6 grades adjustable
Zoned Control
>> Devide the panel into two parts to control probe A and probe B seperately.
Double-safty Facilities
>>Use the start-up key and emergency button for safety.
Dual Metal Probes
Probe A
Probe A is used as the laser acupuncture to irradiate the small area for acupoint stimulation, anti-inflammatory and reduce
swelling edema.
Probe B
Probe B is used to irradiate the parts like bone joint, muscle, ligament, neck and back for pain relief, tissue repair and rehabilitation.
Used by high quality imported laser diode which has the long life-span and stable performance.
Low Level Laser
Low level lasers are a group of lasers with a power less than 500 mW and unlike high-power lasers they have no effect on tissue temperature.
Low level lasers produce light-dependent chemical reactions in tissues to relieve the pain. It nearly eliminates pain and inflammation, restores normal body function without using painkillers.
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