ESSENTIALS OF DIAGNOSIS
Monoclonal IgM paraprotein.
Infiltration of bone marrow by plasmacytic lymphocytes.
Absence of lytic bone disease.
Waldenström macroglobulinemia is a syndrome of IgM hypergammaglobulinemia that occurs in the setting of a low-grade non-Hodgkin lymphoma characterized by B cells that are morphologically a hybrid of lymphocytes and plasma cells. These cells characteristically secrete the IgM paraprotein, and many clinical manifestations of the disease are related to this macroglobulin.
This disease characteristically develops insidiously in patients in their 60s or 70s. Patients usually present with fatigue related to anemia. Hyperviscosity of serum may be manifested in a number of ways. Mucosal and gastrointestinal bleeding is related to engorged blood vessels and platelet dysfunction. Other complaints include nausea, vertigo, and visual disturbances (eFigure 13–36). Alterations in consciousness vary from mild lethargy to stupor and coma. The IgM paraprotein may also cause symptoms of cold agglutinin disease (hemolysis) or chronic demyelinating peripheral neuropathy.
Hyperviscosity syndrome. Dilated arteries and veins, with hemorrhages and microaneurysms, in a patient with hyperviscosity due to elevated IgM levels. (Reproduced, with permission, from Vaughan DG, Asbury T, Riordan-Eva P [editors]. General Ophthalmology, 15th ed. Originally published by Appleton & Lange. Copyright © 1999 by The McGraw-Hill Companies, Inc.)
On examination, there may be hepatosplenomegaly or lymphadenopathy. The retinal veins are engorged. Purpura may be present. There should be no bone tenderness.
Anemia is nearly universal, and rouleaux formation is common, although the red blood cells are agglutinated when the blood smear is prepared at room temperature. The anemia is related in part to expansion of the plasma volume by 50–100% due to the presence of the paraprotein. Other blood counts are usually normal. The abnormal plasmacytic lymphocytes may appear in small numbers on the peripheral blood smear. The bone marrow is characteristically infiltrated by the plasmacytic lymphocytes.
The hallmark of macroglobulinemia is the presence of a monoclonal IgM spike seen on serum PEP in the beta-globulin region. The serum viscosity is usually increased above the normal of 1.4–1.8 times that of water. Symptoms of hyperviscosity usually develop when the serum viscosity is over four times that of water, and marked symptoms usually arise when the viscosity is over six times that of water. Because paraproteins vary in their physicochemical properties, there is no strict correlation between the concentration of paraprotein and serum viscosity.
The IgM paraprotein may cause a positive antiglobulin (Coombs) test for complement and have cold agglutinin or cryoglobulin properties. If macroglobulinemia is suspected but the serum PEP shows only hypogammaglobulinemia, the test should be repeated while taking special measures to maintain the blood at 37°C, ...