Waldenström's macroglobulinemia physical examination

Waldenström's macroglobulinemia Microchapters
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sara Mohsin, M.D.[2] Mirdula Sharma, MBBS [3]

Overview

Patients with Waldenström macroglobulinemia usually appear oriented to time, place, and person. Physical examination of patients with Waldenström's macroglobulinemia is usually remarkable for various findings depending on the degree of tissue infiltration by malignant tumor cells, hyperviscosity syndrome, and accumulation of paraprotein.

Physical Examination

General Appearance

Patients with Waldenström macroglobulinemia are generally well-appearing.

Skin

• Maculopapular lesions, plaques, or nodules
• Purpura
• Raynaud phenomenon
• Petechiae (if platelet count is low)
• Skin ulcers
• Skin necrosis
• Cold urticaria
• Firm, flesh-colored skin papules and nodules also called macroglobulinemia cutis

Lesion measuring 4 centimeters on penis base, with a clear backgroundSource: Oliveira CC. et al, Universidade do Oeste Paulista, Presidente Prudente, SP, Brazil.

Hyperpigmented nodules with hemorrhagic crusting on the back.Source: Haider S. et al, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA.

The patient presented with tingling ulcers on the feet. [Copyright: ©2013 Fischer et al.]Figure 1B. On further examination, papules were noted on the knees. [Copyright: ©2013 Fischer et al.]Figure1C. Biopsy from a knee papule showed homogeneous extra-vascular eosinophilic hyaline deposits throughout the papillary and reticular dermis (H&E 40×). [Copyright: ©2013 Fischer et al.]Figure 1D. IgM stain demonstrates the extravascular IgM deposits in the dermis (40×). [Copyright: ©2013 Fischer et al.]Source: Fischer I. et al, Department of Dermatology, Klinikum Schwabing, Munich, Germany.

HEENT

• Pallor
• Papilledema
• Malignant vitreitis
• Congestion/sludging of blood in conjunctival vessels
• Retinitis/retinopathy including dilation, segmentation and tortuosity of retinal vessels, mid-peripheral retinal hemorrhages, serous retinal/macular neurosensory detachment, blurred disc margins and fundal exudates on fundoscopic examination

Ophthalmoscopic examination revealed dilatation and tortuosity of the retinal veins.Source: Kim YL. et al, Department of Internal Medicine, Eulji University College of Medicine, Seoul, Korea.

Ophthalmologic findings in the presented case. Optic disk of the left eye is shown. Perivenous sheathing is indicated (black arrow).Source: Nipp R. et al, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA.

One year after therapy. The right fundus exhibited a roundish, subretinal, pseudovitelliform deposit (a). The deposit displayed uneven hyper-autofluorescence on a fundus autofluorescent photograph (c) and an uneven staining in fluorescein angiography (e). It was associated with macular edema in an OCT horizontal scan (g). The left eye fundus exhibited a large retinal serous detachment (b), with accumulation of hyper-autofluorescent lipofuscin material in autofluorescence fundus photography (d). Fluorescin angiography was not contributive (f), but OCT showed the absence of central photoreceptors (h).Source: Brolly A. et al, Department of Ophthalmology, APHP, Hôpital Lariboisière, University Paris Diderot, Sorbonne Paris Cité, Bourges, France.

Fluorescein angiography: Hyperviscosity syndrome characterized by bilateral retinal venous dilation and tortuosity, retinal hemorrhages and peripheral microaneurisms.Source: Brolly A. et al, Department of Ophthalmology, APHP, Hôpital Lariboisière, University Paris Diderot, Sorbonne Paris Cité, Bourges, France.

Neck

• Lymphadenopathy
• Jugular venous distension

Respiratory

• Pleural effusion - in 3-5% of patients
• Rales on auscultation
• Pulmonary infiltrates, nodules, masses

Cardiovascular system

• Displaced apical impulse
• S3 gallop

Abdomen

• Swollen abdomen/belly
• Splenomegaly
• Hepatomegaly

Extremity

• Raynaud phenomenon
• Patients may have peripheral edema if disease is complicated by congestive heart failure

Neuromuscular

• Peripheral neuropathy - distal, symmetric, and sensorimotor