Correspondence

Marked Increase in Serum IgM during Treatment of Waldenström's Macroglobulinemia with Cladribine

N Engl J Med 2003; 348:2045-2046May 15, 2003

Article

To the Editor:

We recently encountered two patients with Waldenström's macroglobulinemia1 who had a marked increase in the serum concentration of IgM M component during treatment with cladribine.2 Patient 1, a 78-year-old woman, reported shortness of breath and fatigue of two weeks' duration. Physical examination, a complete blood count, and serum chemical values were normal. An IgM-kappa M component was detected in serum; the total serum IgM concentration was 2580 mg per deciliter. A biopsy of a mass in the right side of the chest and right kidney revealed a B-cell lymphoma with plasma-cell differentiation. The bone marrow was also affected, with lymphoplasmacytic lymphoma. Four days after the first five-day treatment with cladribine, the concentration of IgM increased to 5900 mg per deciliter (Figure 1Figure 1Concentration of IgM during and after Treatment with Cladribine.); serum viscosity was 3.7 relative viscosity units.

Patient 2, a 64-year-old man, reported a six-month history of abdominal bloating and diarrhea. Physical examination, a complete blood count, and serum chemical values were normal. An IgM-kappa M component was detected in serum; the total serum IgM concentration was 2360 mg per deciliter. Colonoscopy showed polypoid lesions extending from the cecum to the descending colon. Biopsy findings were interpreted as showing an extranodal, marginal-zone B-cell lymphoma; the bone marrow was also affected by lymphoma. Ten days after the first five-day treatment with cladribine, the concentration of IgM peaked at 3600 mg per deciliter (Figure 1); the serum viscosity was 2.3 relative viscosity units.

We suggest that the marked increase in the serum IgM concentration in these two patients resulted from lysis of tumor cells by cladribine. We draw attention to these cases because, although neither patient had the hyperviscosity syndrome,3 similar patients with higher initial concentrations of IgM M component (e.g., 4 to 5 g per deciliter) might have the hyperviscosity syndrome as a consequence of this newly discovered manifestation of the tumor lysis syndrome.4 Plasmapheresis might be considered, before treatment with cladribine, in such patients.

Vandana M. Krishna, M.D.
Robert W. Carey, M.D.
Kurt J. Bloch, M.D.
Massachusetts General Hospital, Boston, MA 02114
vank01@yahoo.com

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Citing Articles (6)

Citing Articles

1. 1

   Rafael Fonseca, Suzanne Hayman. (2007) Waldenström macroglobulinaemia. British Journal of Haematology 138:6, 700-720
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2. 2

   Stephen A Johnson. (2006) Advances in the treatment of Waldenström’s macroglobulinemia. Expert Review of Anticancer Therapy 6:3, 329-334
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3. 3

   S. A. Johnson, J. Birchall, C. Luckie, D. G. Oscier, R. G. Owen. (2006) Guidelines on the management of Waldenstrom macroglobulinaemia*. British Journal of Haematology 132:6, 683-697
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4. 4

   Morie A. Gertz. (2005) Waldenström macroglobulinemia: A review of therapy. American Journal of Hematology 79:2, 147-157
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5. 5

   Irene M. Ghobrial, Rafael Fonseca, Philip R. Greipp, Emily Blood, Montserrat Rue, David H. Vesole, Morie A. Gertz. (2004) Initial immunoglobulin M ?flare? after rituximab therapy in patients diagnosed with Waldenstrom macroglobulinemia. Cancer 101:11, 2593-2598
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6. 6

   &NA;. (2003) Cladribine. Reactions Weekly &NA;:952, 9
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