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Plante MM, Kimbrough EO, Agarwal AK, Jiang L, Bourgeois K, Stamper GC, Stewart MW, Tun HW. Hyperviscosity Syndrome Induced Bilateral Visual and Auditory Impairment in Therapy Resistant Waldenström Macroglobulinemia with MYD88 and CXCR4 Mutations. J Blood Med 2023; 14:639-648. [PMID: 38116327 PMCID: PMC10729678 DOI: 10.2147/jbm.s424072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 11/21/2023] [Indexed: 12/21/2023] Open
Abstract
Hyperviscosity syndrome (HVS) is an emergent complication of Waldenström macroglobulinemia (WM) characterized by visual, neurologic, and rarely auditory impairment. We report a 69-year-old female with MYD88 and CXCR4-mutant WM who developed HVS resulting in bilateral blindness and deafness associated with neurologic manifestations including confusion, severe generalized weakness, and imbalance. Ophthalmologic evaluation revealed bilateral central retinal vein occlusion (CRVO), diffuse retinal hemorrhages, macular edema, and serous macular detachments (SMD). Magnetic resonance imaging of the brain showed bleeding in the inner ears. Management was challenging as her WM was resistant to systemic therapies including bendamustine + rituximab (BR) and rituximab + bortezomib + dexamethasone (RVD). Bruton's tyrosine kinase inhibitors could not be used initially due to ongoing lower gastrointestinal bleeding. She required five total sessions of plasma exchange and was finally initiated on zanubrutinib, achieving a partial response. She also received intravitreal bevacizumab with rapid resolution of the retinal hemorrhages but with little improvement of the SMD. She had partial restoration of her hearing in the right ear and only slight improvement in her bilateral visual deficits. The management of HVS in frail, elderly patients with therapy-resistant WM can be challenging. In these cases, plasma exchange is required until an effective systemic therapy can be safely instituted. Genomic profiling is important in the management of WM as it can predict treatment resistance and guide therapeutic decisions.
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Affiliation(s)
- Marie M Plante
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | - Amit K Agarwal
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Liuyan Jiang
- Department of Pathology, Mayo Clinic, Jacksonville, FL, USA
| | - Kirk Bourgeois
- Department of Pathology, Mayo Clinic, Jacksonville, FL, USA
| | - Greta C Stamper
- Department of Otolaryngology and Audiology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Han W Tun
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL, USA
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Czakó C, Gerencsér D, Kormányos K, Kéki-Kovács K, Németh O, Tóth G, Sándor GL, Csorba A, Langenbucher A, Nagy ZZ, Varga G, Gopcsa L, Mikala G, Kovács I, Szentmáry N. Evaluation of Retinal Blood Flow in Patients with Monoclonal Gammopathy Using OCT Angiography. J Clin Med 2023; 12:5227. [PMID: 37629268 PMCID: PMC10456010 DOI: 10.3390/jcm12165227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/28/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Monoclonal gammopathy (MG) is characterized by monoclonal protein overproduction, potentially leading to the development of hyperviscosity syndrome. OBJECTIVE To assess retinal circulation using optical coherence tomography angiography (OCTA) parameters in patients with monoclonal gammopathy. METHODS OCTA measurements were performed using the Optovue AngioVue system by examining 44 eyes of 27 patients with MG and 62 eyes of 36 control subjects. Superficial and deep retinal capillary vessel density (VD SVP and DVP) in the whole 3 × 3 mm macular and parafoveal area, foveal avascular zone (FAZ) area, and central retinal thickness (CRT) were measured using the AngioAnalytics software. The OCTA parameters were evaluated in both groups using a multivariate regression model, after controlling for the effect of imaging quality (SQ). RESULTS There was no significant difference in age between the subjects with monoclonal gammopathy and the controls (63.59 ± 9.33 vs. 58.01 ± 11.46 years; p > 0.05). Taking into account the effect of image quality, the VD SVP was significantly lower in the MG group compared to the control group (44.54 ± 3.22% vs. 46.62 ± 2.84%; p < 0.05). No significant differences were found between the two groups regarding the other OCTA parameters (p > 0.05). CONCLUSIONS A decreased superficial retinal capillary vessel density measured using OCTA in patients with MG suggests a slow blood flow, reduced capillary circulation, and consequent tissue hypoperfusion. An evaluation of retinal circulation using OCTA in cases of monoclonal gammopathy may be a sensitive method for the non-invasive detection and follow-up of early microcirculatory dysfunction caused by increased viscosity.
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Affiliation(s)
- Cecilia Czakó
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary
| | - Dóra Gerencsér
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary
| | - Kitti Kormányos
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary
| | | | - Orsolya Németh
- Department of Ophthalmology, Markusovszky University Teaching Hospital, 9700 Szombathely, Hungary
| | - Gábor Tóth
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary
| | | | - Anita Csorba
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary
| | | | - Zoltán Zsolt Nagy
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary
| | - Gergely Varga
- 3rd Department of Internal Medicine and Haematology, Semmelweis University, 1085 Budapest, Hungary
| | - László Gopcsa
- Department of Haematology and Stem Cell-Transplantation, South-Pest Central Hospital-National Institute for Hematology and Infectious Diseases, 1097 Budapest, Hungary
| | - Gábor Mikala
- Department of Haematology and Stem Cell-Transplantation, South-Pest Central Hospital-National Institute for Hematology and Infectious Diseases, 1097 Budapest, Hungary
| | - Illés Kovács
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary
- Department of Ophthalmology, Weill Cornell Medical College, New York City, NY 10065, USA
| | - Nóra Szentmáry
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary
- Dr. Rolf M. Schwiete Center for Limbal Stem Cell and Congenital Aniridia Research, Saarland University, 66424 Homburg, Germany
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