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The serum abnormal immunoglobulin in the blood was cryoglobulin, which typically precipitates in the tissues at low temperatures causing inflammation and tissue damage. Histopathological changes, observed in lesions at different evolutionary stages, evidenced columns of horny\u2010like 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\u2010necrotic lesion revealed cryoprecipitates containing IgG\u2010lambda with electrophoretic characteristics identical to those of the serum dysprotein. Our findings suggest that the formation of spicules and development of ulcerative lesions are a part of the same clinical spectrum where the cold\u2010dependent 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\u2010risk cytogenetic abnormalities and be incorporated into prognostic models, applicable early on in the course of myeloma, warrants further investigation.<\/jats:p>","DOI":"10.1111\/cup.13523","type":"journal-article","created":{"date-parts":[[2019,6,4]],"date-time":"2019-06-04T09:03:34Z","timestamp":1559639014000},"page":"844-851","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Eruptive ulcerative follicular spicules heralding progression of smoldering multiple myeloma"],"prefix":"10.1111","volume":"46","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8383-3443","authenticated-orcid":false,"given":"Carlo","family":"Tomasini","sequence":"first","affiliation":[{"name":"Department of Clinical\u2010Surgical, Diagnostic, and Pediatric Sciences, Institute of Dermatology IRCCS Fondazione Policlinico San Matteo, University of Pavia  Pavia Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea","family":"Michelerio","sequence":"additional","affiliation":[{"name":"Department of Clinical\u2010Surgical, Diagnostic, and Pediatric Sciences, Institute of Dermatology IRCCS Fondazione Policlinico San Matteo, University of Pavia  Pavia Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Valeria","family":"Brazzelli","sequence":"additional","affiliation":[{"name":"Department of Clinical\u2010Surgical, Diagnostic, and Pediatric Sciences, Institute of Dermatology IRCCS Fondazione Policlinico San Matteo, University of Pavia  Pavia Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2019,6,27]]},"reference":[{"key":"e_1_2_5_2_1","doi-asserted-by":"publisher","DOI":"10.1155\/2014\/864058"},{"key":"e_1_2_5_3_1","doi-asserted-by":"publisher","DOI":"10.1067\/mjd.2003.180"},{"key":"e_1_2_5_4_1","doi-asserted-by":"publisher","DOI":"10.1053\/j.seminoncol.2016.02.017"},{"key":"e_1_2_5_5_1","doi-asserted-by":"publisher","DOI":"10.1111\/jdv.13847"},{"key":"e_1_2_5_6_1","first-page":"192","article-title":"Haut und Gelenkver\u00e4nderungen bei multiplem Myelom","volume":"24","author":"Heidenstr\u00f6m N","year":"1944","journal-title":"Acta Derm Venereol"},{"key":"e_1_2_5_7_1","first-page":"127","volume-title":"Skin Signs of Systemic Disease","author":"Braverman IM","year":"1970"},{"key":"e_1_2_5_8_1","first-page":"411","article-title":"Syndrome paran\u00e9oplasique avec l\u00e9sions papulo\u2010keratosique des extremit\u00e9s et k\u00e9ratose pilaire spinulosique diffuse","volume":"101","author":"Nazzaro P","year":"1974","journal-title":"Ann Derm Syph"},{"key":"e_1_2_5_9_1","doi-asserted-by":"publisher","DOI":"10.1001\/archderm.1985.01660060109033"},{"key":"e_1_2_5_10_1","first-page":"45","volume-title":"Dia\u2010Klinik","author":"Brunner R","year":"1987"},{"key":"e_1_2_5_11_1","first-page":"71","volume-title":"Dia\u2010Klinik","author":"Castonet P","year":"1987"},{"key":"e_1_2_5_12_1","first-page":"795","article-title":"Parakeratotic horns in a patient with myeloma","volume":"121","author":"Kuokkanen K","year":"1985","journal-title":"J Cutan Pathol"},{"key":"e_1_2_5_13_1","doi-asserted-by":"publisher","DOI":"10.1001\/archderm.1990.01670280093017"},{"key":"e_1_2_5_14_1","doi-asserted-by":"publisher","DOI":"10.1016\/0190-9622(95)91431-5"},{"key":"e_1_2_5_15_1","doi-asserted-by":"publisher","DOI":"10.1016\/0190-9622(95)91542-7"},{"key":"e_1_2_5_16_1","doi-asserted-by":"publisher","DOI":"10.1159\/000063918"},{"key":"e_1_2_5_17_1","doi-asserted-by":"publisher","DOI":"10.1067\/S0190-9622(03)00122-1"},{"key":"e_1_2_5_18_1","doi-asserted-by":"publisher","DOI":"10.1001\/archderm.142.12.1665"},{"key":"e_1_2_5_19_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0001-7310(06)73475-5"},{"key":"e_1_2_5_20_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1440-0960.2008.00484.x"},{"key":"e_1_2_5_21_1","doi-asserted-by":"publisher","DOI":"10.1001\/archdermatol.2009.33-a"},{"key":"e_1_2_5_22_1","first-page":"709","article-title":"Multiple myeloma unveiled by multiple hyperkeratotic spicules","volume":"12","author":"Dalal A","year":"2010","journal-title":"Isr Med Assoc J"},{"key":"e_1_2_5_23_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-4632.2009.04369.x"},{"key":"e_1_2_5_24_1","doi-asserted-by":"publisher","DOI":"10.1001\/jamadermatol.2014.1616"},{"key":"e_1_2_5_25_1","doi-asserted-by":"publisher","DOI":"10.2340\/00015555-1751"},{"key":"e_1_2_5_26_1","article-title":"Early detection of IgH monoclonal rearrangenent in follicular spicules of the nose preceding multiple myeloma diagnosis. 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