PAULA DAVIS, Senior Assistant Resident in Medicine, The Jewish Hospital of St Louis: A 56-year-old man, admitted to the hospital because of pancytopenia and oral thrush, was first noted to have inguinal lymphadenopathy on a routine examination in 1969. A lymph node biopsy specimen taken in 1972 was interpreted initially as showing changes consistent with lymphosarcoma, and treatment with cobalt irradiation was initiated. Chemotherapy was subsequently given for progressive lymphadenopathy. Subsequently, hypergammaglobulinemia (5.9 g/dL), an elevated serum viscosity (4.8 times water), and a monoclonal IgM "spike" were described. Analysis of a bone marrow biopsy specimen confirmed the diagnosis of Waldenström's macroglobulinemia. Prednisone and chlorambucil were given during the next seven years. Subsequent relapses were treated intermittently with chlorambucil.
In 1979, the patient was admitted to the hospital with increasing fatigue, lymphadenopathy, and hepatosplenomegaly. An abdominal computed tomographic (CT) scan disclosed enlarged pelvic and retroperitoneal lymph nodes. He was treated with