Hyperglobulinemic purpura of Waldenström
Hyperglobulinemic purpura of Waldenström is classified as primary (idiopathic) or secondary to an underlying disease. Associated diseases include autoimmune connective tissue disorders, most commonly Sjögren syndrome; occasionally systemic lupus erythematosus, rheumatoid arthritis, autoimmune hepatitis, hepatitis C, or cystic fibrosis; and rarely hematologic malignancies, such as monoclonal gammopathy, lymphoma, or multiple myeloma. The onset of hypergammaglobulinemic purpura often precedes the underlying disease by many years, with some associated diseases developing 10 or more years later. Autoantibodies that are commonly positive include Ro/SS-A, La/SS-B, antinuclear antibodies (ANA), and rheumatoid factor (RF). The presence of anti-Ro/SS-A and anti-La/SS-B antibodies may predict a higher likelihood of developing an associated autoimmune connective tissue disorder. Mild anemia or lymphopenia can also be found.
The petechiae and purpura are frequently exacerbated by prolonged periods of standing, wearing tight clothing, alcohol intake, and exercise. The eruption is usually asymptomatic, yet some patients may report burning, stinging, pruritus, or lower extremity swelling. The pathogenesis of purpura is thought to be due to immune complex deposition in the blood vessels of the lower extremities. Truncal involvement can also be seen.
When this condition is seen in pregnancy, it is not considered benign; all reported cases are associated with anti-SS-A antibodies, with potential increased risk of poor maternal / fetal outcome including intrauterine fetal growth restriction, congenital heart block, and fetal demise. More than half of children, as reported in the literature, will go on to develop an autoimmune condition.
D89.0 – Polyclonal hypergammaglobulinemia
190809001 – Waldenstrom hypergammaglobulinemic purpura
Differential Diagnosis & Pitfalls
- (formerly Henoch-Schönlein purpura) – Characteristic clinical tetrad of palpable purpura, abdominal pain, arthritis, and hematuria and typical histopathologic findings of leukocytoclastic vasculitis with IgA deposition in blood vessel walls.
- – Classic presentation is palpable purpura; histopathologic findings are typical of leukocytoclastic vasculitis.
- – Purpura is more copper-brown in color ("cayenne pepper" appearance); males are more frequently affected; no associated underlying disease.
- Purpuric – Rare disorder resulting from allergy to textile dyes and resins; patch testing will reveal responsible allergens.
- – Can appear as pigmented purpura-like eruption, differentiated histopathologically.
- (ITP) – Petechiae, purpura, and characteristic history of bleeding and low platelet count in setting of normal bone marrow; absence of disease or medication associated with thrombocytopenia.
- (TTP) – Petechiae and purpura tend to be smaller in size with characteristic clinical pentad of thrombocytopenia, microangiopathic hemolytic anemia (presence of schistocytes on peripheral blood smear), renal failure, neurologic deficits, and fever.
- – Inadequate vitamin C intake, perifollicular purpura, corkscrew hairs, spongy bleeding gums, and low fasting ascorbic acid levels.