Lymphoplasmacytic lymphoma laboratory findings: Difference between revisions
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==Overview== | ==Overview== | ||
[[Laboratory]] findings consistent with the [[diagnosis]] of [[lymphoplasmacytic lymphoma]] include any [[cytopenia]], [[lymphocytosis]], [[monocytosis]], elevated levels of [[Lactate dehydrogenase|LDH]], [[Beta-2 microglobulin]], [[uric acid]], and [[urea]] & [[creatinine]], elevated [[Erythrocyte sedimentation rate|ESR]], [[hypercalcemia]], [[hyponatremia]], positive [[rheumatoid factor]], positive [[cryoglobulins]], positive direct anti-[[globulin]] [[test]], positive [[cold agglutinin titre]], [[proteinuria]], prolonged [[bleeding time]], prolonged [[prothrombin time]], prolonged [[activated partial thromboplastin time]], prolonged [[thrombin time]] and [[peripheral smear]] shows [[plasmacytoid]] [[lymphocytes]], [[Normocytic normochromic anemia|normocytic normochromic red blood cells]] and [[rouleaux formation]]. | |||
==Laboratory Findings== | ==Laboratory Findings== | ||
* | *[[Lymphoplasmacytic lymphoma|LPL]] is mostly suspected when a [[patient]] has low [[blood counts]] and/or high levels of unusual [[protein]] levels on [[blood tests]]. | ||
* Usually after that, a [[blood test]] called [[serum protein electrophoresis]] is ordered to find out what type of [[protein]] is there. | * Usually after that, a [[blood test]] called [[serum protein electrophoresis]] is ordered to find out what type of [[protein]] is there. | ||
* Mostly, only after these tests are done that a [[biopsy]] of either the [[bone marrow]] or a [[lymph node]] is considered to confirm the LPL [[diagnosis]]. | * Mostly, only after these [[Test|tests]] are done that a [[biopsy]] of either the [[bone marrow]] or a [[lymph node]] is considered to confirm the [[Lymphoplasmacytic lymphoma|LPL]] [[diagnosis]]. | ||
* Laboratory findings consistent with the [[diagnosis]] of [[lymphoplasmacytic lymphoma]] include:<ref name="pmid11736938">{{cite journal| author=García-Sanz R, Montoto S, Torrequebrada A, de Coca AG, Petit J, Sureda A et al.| title=Waldenström macroglobulinaemia: presenting features and outcome in a series with 217 cases. | journal=Br J Haematol | year= 2001 | volume= 115 | issue= 3 | pages= 575-82 | pmid=11736938 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11736938 }} </ref> | *[[Laboratory]] findings consistent with the [[diagnosis]] of [[lymphoplasmacytic lymphoma]] include:<ref name="pmid11736938">{{cite journal| author=García-Sanz R, Montoto S, Torrequebrada A, de Coca AG, Petit J, Sureda A et al.| title=Waldenström macroglobulinaemia: presenting features and outcome in a series with 217 cases. | journal=Br J Haematol | year= 2001 | volume= 115 | issue= 3 | pages= 575-82 | pmid=11736938 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11736938 }} </ref> | ||
===Complete blood count=== | ===Complete blood count=== | ||
*[[Anemia]] | *[[Anemia]]: | ||
**Seen in 40% of newly diagnosed patients and in 80% of [[symptomatic]] patients with [[lymphoplasmacytic lymphoma]] | **Seen in 40% of [[New|newly]] [[Diagnose|diagnosed]] [[patients]] and in 80% of [[symptomatic]] [[patients]] with [[lymphoplasmacytic lymphoma]] | ||
**Multi-factorial [[causes]] including: decreased [[RBC]] synthesis due to [[bone marrow infiltration]], [[iron deficiency]] due to [[gastrointestinal bleeding]], and [[chronic inflammation]] | **Multi-factorial [[causes]] including: decreased [[RBC]] [[synthesis]] due to [[bone marrow infiltration]], [[iron deficiency]] due to [[gastrointestinal bleeding]], and [[chronic inflammation]] | ||
*[[Thrombocytopenia]] | *[[Thrombocytopenia]]: | ||
**Due to [[bone marrow]] [[Infiltration (medical)|infiltration]] | **Due to [[bone marrow]] [[Infiltration (medical)|infiltration]] | ||
*[[Neutropenia]] | *[[Neutropenia]]: | ||
**Due to [[bone marrow]] [[Infiltration (medical)|infiltration]] | **Due to [[bone marrow]] [[Infiltration (medical)|infiltration]] | ||
*[[Lymphocytosis]] | *[[Lymphocytosis]] | ||
| Line 26: | Line 26: | ||
*[[Normocytic normochromic anemia|Normocytic normochromic red blood cells]] | *[[Normocytic normochromic anemia|Normocytic normochromic red blood cells]] | ||
*[[Rouleaux formation]] | *[[Rouleaux formation]] | ||
===Chemistry Lab tests===<ref name="pmid19520758">{{cite journal| author=Katzmann JA, Kyle RA, Benson J, Larson DR, Snyder MR, Lust JA et al.| title=Screening panels for detection of monoclonal gammopathies. | journal=Clin Chem | year= 2009 | volume= 55 | issue= 8 | pages= 1517-22 | pmid=19520758 | doi=10.1373/clinchem.2009.126664 | pmc=3773468 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19520758 }} </ref> | ===Chemistry Lab tests=== | ||
*Elevated [[lactate dehydrogenase]] ([[LDH]]):<ref name="pmid19520758">{{cite journal| author=Katzmann JA, Kyle RA, Benson J, Larson DR, Snyder MR, Lust JA et al.| title=Screening panels for detection of monoclonal gammopathies. | journal=Clin Chem | year= 2009 | volume= 55 | issue= 8 | pages= 1517-22 | pmid=19520758 | doi=10.1373/clinchem.2009.126664 | pmc=3773468 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19520758 }} </ref> | |||
**Level indicates the extent of the disease | **Level indicates the extent of the [[disease]] | ||
*Elevated [[urea]] and [[creatinine]] | *Elevated [[urea]] and [[creatinine]] | ||
**Rarely | **[[Rare|Rarely]] | ||
*[[Electrolyte abnormalities]] | *[[Electrolyte abnormalities]] | ||
**[[Hypercalcemia]] | **[[Hypercalcemia]] | ||
**[[Hyponatremia]] | **[[Hyponatremia]] | ||
*Elevated [[erythrocyte sedimentation rate]] ([[ESR]]) | *Elevated [[erythrocyte sedimentation rate]] ([[ESR]]) | ||
*[[ | *Elevated [[uric acid]] levels | ||
*Elevated [[beta-2-microglobulin]] in proportion to [[tumor]] mass | *Positive [[rheumatoid factor]] | ||
*Positive [[cryoglobulins]] | |||
*Positive direct anti-[[globulin]] [[test]] | |||
*Positive [[cold agglutinin titre]] | |||
*Elevated [[beta-2-microglobulin]] in [[Proportionality (mathematics)|proportion]] to [[tumor]] [[mass]] | |||
**Needed to evaluate [[prognosis]] | **Needed to evaluate [[prognosis]] | ||
===Platelet function test and blood coagulation studies=== | ===Platelet function test and blood coagulation studies=== | ||
*Prolonged [[bleeding time]]<ref name="pmid4924493">{{cite journal| author=Penny R, Castaldi PA, Whitsed HM| title=Inflammation and haemostasis in paraproteinaemias. | journal=Br J Haematol | year= 1971 | volume= 20 | issue= 1 | pages= 35-44 | pmid=4924493 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4924493 }} </ref> | *Prolonged [[bleeding time]]<ref name="pmid4924493">{{cite journal| author=Penny R, Castaldi PA, Whitsed HM| title=Inflammation and haemostasis in paraproteinaemias. | journal=Br J Haematol | year= 1971 | volume= 20 | issue= 1 | pages= 35-44 | pmid=4924493 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4924493 }} </ref> | ||
**Possibly due to interaction between [[platelet]] membrane [[Glycoprotein|glycoproteins]] and [[IgM]] [[paraprotein]] | **Possibly due to [[interaction]] between [[platelet]] [[membrane]] [[Glycoprotein|glycoproteins]] and [[IgM]] [[paraprotein]] | ||
* | *Prolonged [[prothrombin time]] | ||
*Prolonged [[activated partial thromboplastin time]] | |||
*Prolonged [[thrombin time]] | |||
*[[Abnormalities]] related to [[fibrinogen]] levels | |||
===Mutational analysis=== | ===Mutational analysis=== | ||
*'''[[MYD88]]''' [[gene]] [[mutation]] has been found in more than 90% of patients with [[lymphoplasmacytic lymphoma]]<ref name="pmid23321251">{{cite journal| author=Xu L, Hunter ZR, Yang G, Zhou Y, Cao Y, Liu X et al.| title=MYD88 L265P in Waldenström macroglobulinemia, immunoglobulin M monoclonal gammopathy, and other B-cell lymphoproliferative disorders using conventional and quantitative allele-specific polymerase chain reaction. | journal=Blood | year= 2013 | volume= 121 | issue= 11 | pages= 2051-8 | pmid=23321251 | doi=10.1182/blood-2012-09-454355 | pmc=3596964 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23321251 }} </ref> | *'''[[MYD88]]''' [[gene]] [[mutation]] has been found in more than 90% of [[patients]] with [[lymphoplasmacytic lymphoma]]<ref name="pmid23321251">{{cite journal| author=Xu L, Hunter ZR, Yang G, Zhou Y, Cao Y, Liu X et al.| title=MYD88 L265P in Waldenström macroglobulinemia, immunoglobulin M monoclonal gammopathy, and other B-cell lymphoproliferative disorders using conventional and quantitative allele-specific polymerase chain reaction. | journal=Blood | year= 2013 | volume= 121 | issue= 11 | pages= 2051-8 | pmid=23321251 | doi=10.1182/blood-2012-09-454355 | pmc=3596964 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23321251 }} </ref><ref name="pmid27722129">{{cite journal| author=Shin SY, Lee ST, Kim HY, Park CH, Kim HJ, Kim JW et al.| title=Detection of MYD88 L265P in patients with lymphoplasmacytic lymphoma/Waldenstrom macroglobulinemia and other B-cell non-Hodgkin lymphomas. | journal=Blood Res | year= 2016 | volume= 51 | issue= 3 | pages= 181-186 | pmid=27722129 | doi=10.5045/br.2016.51.3.181 | pmc=5054250 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27722129 }}</ref> | ||
===Cryocrit=== | ===Cryocrit=== | ||
*This test measures the [[blood]] levels of [[cryoglobulins]] ([[proteins]] that clump together in cool [[temperatures]] and can block [[blood vessels]]) | *This [[test]] [[Measure (mathematics)|measures]] the [[blood]] levels of [[cryoglobulins]] ([[proteins]] that clump together in cool [[temperatures]] and can [[Blockhead|block]] [[blood vessels]]) | ||
===Cold agglutinins=== | ===Cold agglutinins=== | ||
*[[Cold agglutinins]] are [[antibodies]] that attack and kill [[red blood cells]], especially at cooler temperatures. These dead cells can then build up and block [[blood vessels]]. A blood test can be used to detect these [[antibodies]]. | *[[Cold agglutinins]] are [[antibodies]] that [[Attack rate|attack]] and kill [[red blood cells]], especially at cooler [[temperatures]]. | ||
*These [[Dead body|dead]] [[Cells (biology)|cells]] can then [[Building biology|build]] up and [[Blockhead|block]] [[blood vessels]]. | |||
*A [[blood test]] can be used to [[Detection theory|detect]] these [[antibodies]]. | |||
===Beta-2 microglobulin (β2M)=== | ===Beta-2 microglobulin (β2M)=== | ||
*This test measures another [[protein]] made by the [[cancer cells]] in LPL. This [[protein]] itself doesn’t cause any problems, but it’s a useful indicator of a patient’s [[prognosis]] (outlook). High levels of β2M are linked with a worse outlook. | *This [[test]] [[Measure (data warehouse)|measures]] another [[protein]] made by the [[cancer cells]] in LPL.<ref name="pmid25325033">{{cite journal| author=Yoo C, Yoon DH, Suh C| title=Serum beta-2 microglobulin in malignant lymphomas: an old but powerful prognostic factor. | journal=Blood Res | year= 2014 | volume= 49 | issue= 3 | pages= 148-53 | pmid=25325033 | doi=10.5045/br.2014.49.3.148 | pmc=4188779 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25325033 }}</ref><ref name="pmid4558655">{{cite journal| author=Peterson PA, Cunningham BA, Berggård I, Edelman GM| title=2 -Microglobulin--a free immunoglobulin domain. | journal=Proc Natl Acad Sci U S A | year= 1972 | volume= 69 | issue= 7 | pages= 1697-701 | pmid=4558655 | doi=10.1073/pnas.69.7.1697 | pmc=426781 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4558655 }}</ref> | ||
=== | *This [[protein]] itself doesn’t [[Causes|cause]] any problems, but it’s a useful [[indicator]] of a [[Patient|patient’s]] [[prognosis]] (outlook). | ||
*High levels of β2M are [[Link|linked]] with a worse outlook. | |||
===Urinalysis=== | |||
*[[Proteinuria]] | *[[Proteinuria]] | ||
===Serology=== | ===Hepatitis Serology=== | ||
*[[Hepatitis C]] [[serology]] should be obtained for patients with [[cryoglobulinemia]]. | *[[Hepatitis C]] [[serology]] should be obtained for [[patients]] with [[cryoglobulinemia]]. | ||
*[[Hepatitis B]] [[serology]] should be obtained for patients whose planned treatment includes [[rituximab]]. | *[[Hepatitis B]] [[serology]] should be obtained for [[patients]] whose [[Treatment Planning|planned treatment]] includes [[rituximab]]. | ||
===Antibody titers in patients with peripheral neuropathy=== | ===Antibody titers in patients with peripheral neuropathy=== | ||
*Anti-[[myelin]]-associated [[glycoprotein]] | *Anti-[[myelin]]-[[Association (statistics)|associated]] [[glycoprotein]]<ref name="pmid21320835">{{cite journal| author=Klein CJ, Moon JS, Mauermann ML, Zeldenrust SR, Wu Y, Dispenzieri A et al.| title=The neuropathies of Waldenström's macroglobulinemia (WM) and IgM-MGUS. | journal=Can J Neurol Sci | year= 2011 | volume= 38 | issue= 2 | pages= 289-95 | pmid=21320835 | doi=10.1017/s0317167100011483 | pmc=3901797 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21320835 }}</ref><ref name="pmid16421127">{{cite journal| author=Levine T, Pestronk A, Florence J, Al-Lozi MT, Lopate G, Miller T et al.| title=Peripheral neuropathies in Waldenström's macroglobulinaemia. | journal=J Neurol Neurosurg Psychiatry | year= 2006 | volume= 77 | issue= 2 | pages= 224-8 | pmid=16421127 | doi=10.1136/jnnp.2005.071175 | pmc=2077569 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16421127 }}</ref><ref name="pmid7504399">{{cite journal| author=Baldini L, Nobile-Orazio E, Guffanti A, Barbieri S, Carpo M, Cro L et al.| title=Peripheral neuropathy in IgM monoclonal gammopathy and Wäldenstrom's macroglobulinemia: a frequent complication in elderly males with low MAG-reactive serum monoclonal component. | journal=Am J Hematol | year= 1994 | volume= 45 | issue= 1 | pages= 25-31 | pmid=7504399 | doi=10.1002/ajh.2830450105 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7504399 }}</ref> | ||
*Anti-[[ganglioside]] M1 | *Anti-[[ganglioside]] M1 | ||
*Anti-[[sulfatide]] [[IgM]] [[antibodies]] | *Anti-[[sulfatide]] [[IgM]] [[antibodies]] | ||
Latest revision as of 16:49, 29 October 2019
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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]
Overview
Laboratory findings consistent with the diagnosis of lymphoplasmacytic lymphoma include any cytopenia, lymphocytosis, monocytosis, elevated levels of LDH, Beta-2 microglobulin, uric acid, and urea & creatinine, elevated ESR, hypercalcemia, hyponatremia, positive rheumatoid factor, positive cryoglobulins, positive direct anti-globulin test, positive cold agglutinin titre, proteinuria, prolonged bleeding time, prolonged prothrombin time, prolonged activated partial thromboplastin time, prolonged thrombin time and peripheral smear shows plasmacytoid lymphocytes, normocytic normochromic red blood cells and rouleaux formation.
Laboratory Findings
- LPL is mostly suspected when a patient has low blood counts and/or high levels of unusual protein levels on blood tests.
- Usually after that, a blood test called serum protein electrophoresis is ordered to find out what type of protein is there.
- Mostly, only after these tests are done that a biopsy of either the bone marrow or a lymph node is considered to confirm the LPL diagnosis.
- Laboratory findings consistent with the diagnosis of lymphoplasmacytic lymphoma include:[1]
Complete blood count
- Anemia:
- Seen in 40% of newly diagnosed patients and in 80% of symptomatic patients with lymphoplasmacytic lymphoma
- Multi-factorial causes including: decreased RBC synthesis due to bone marrow infiltration, iron deficiency due to gastrointestinal bleeding, and chronic inflammation
- Thrombocytopenia:
- Due to bone marrow infiltration
- Neutropenia:
- Due to bone marrow infiltration
- Lymphocytosis
- Monocytosis
Peripheral smear
Chemistry Lab tests
- Elevated lactate dehydrogenase (LDH):[2]
- Level indicates the extent of the disease
- Elevated urea and creatinine
- Electrolyte abnormalities
- Elevated erythrocyte sedimentation rate (ESR)
- Elevated uric acid levels
- Positive rheumatoid factor
- Positive cryoglobulins
- Positive direct anti-globulin test
- Positive cold agglutinin titre
- Elevated beta-2-microglobulin in proportion to tumor mass
- Needed to evaluate prognosis
Platelet function test and blood coagulation studies
- Prolonged bleeding time[3]
- Possibly due to interaction between platelet membrane glycoproteins and IgM paraprotein
- Prolonged prothrombin time
- Prolonged activated partial thromboplastin time
- Prolonged thrombin time
- Abnormalities related to fibrinogen levels
Mutational analysis
- MYD88 gene mutation has been found in more than 90% of patients with lymphoplasmacytic lymphoma[4][5]
Cryocrit
- This test measures the blood levels of cryoglobulins (proteins that clump together in cool temperatures and can block blood vessels)
Cold agglutinins
- Cold agglutinins are antibodies that attack and kill red blood cells, especially at cooler temperatures.
- These dead cells can then build up and block blood vessels.
- A blood test can be used to detect these antibodies.
Beta-2 microglobulin (β2M)
- This test measures another protein made by the cancer cells in LPL.[6][7]
- This protein itself doesn’t cause any problems, but it’s a useful indicator of a patient’s prognosis (outlook).
- High levels of β2M are linked with a worse outlook.
Urinalysis
Hepatitis Serology
- Hepatitis C serology should be obtained for patients with cryoglobulinemia.
- Hepatitis B serology should be obtained for patients whose planned treatment includes rituximab.
Antibody titers in patients with peripheral neuropathy
- Anti-myelin-associated glycoprotein[8][9][10]
- Anti-ganglioside M1
- Anti-sulfatide IgM antibodies
References
- ↑ García-Sanz R, Montoto S, Torrequebrada A, de Coca AG, Petit J, Sureda A; et al. (2001). "Waldenström macroglobulinaemia: presenting features and outcome in a series with 217 cases". Br J Haematol. 115 (3): 575–82. PMID 11736938.
- ↑ Katzmann JA, Kyle RA, Benson J, Larson DR, Snyder MR, Lust JA; et al. (2009). "Screening panels for detection of monoclonal gammopathies". Clin Chem. 55 (8): 1517–22. doi:10.1373/clinchem.2009.126664. PMC 3773468. PMID 19520758.
- ↑ Penny R, Castaldi PA, Whitsed HM (1971). "Inflammation and haemostasis in paraproteinaemias". Br J Haematol. 20 (1): 35–44. PMID 4924493.
- ↑ Xu L, Hunter ZR, Yang G, Zhou Y, Cao Y, Liu X; et al. (2013). "MYD88 L265P in Waldenström macroglobulinemia, immunoglobulin M monoclonal gammopathy, and other B-cell lymphoproliferative disorders using conventional and quantitative allele-specific polymerase chain reaction". Blood. 121 (11): 2051–8. doi:10.1182/blood-2012-09-454355. PMC 3596964. PMID 23321251.
- ↑ Shin SY, Lee ST, Kim HY, Park CH, Kim HJ, Kim JW; et al. (2016). "Detection of MYD88 L265P in patients with lymphoplasmacytic lymphoma/Waldenstrom macroglobulinemia and other B-cell non-Hodgkin lymphomas". Blood Res. 51 (3): 181–186. doi:10.5045/br.2016.51.3.181. PMC 5054250. PMID 27722129.
- ↑ Yoo C, Yoon DH, Suh C (2014). "Serum beta-2 microglobulin in malignant lymphomas: an old but powerful prognostic factor". Blood Res. 49 (3): 148–53. doi:10.5045/br.2014.49.3.148. PMC 4188779. PMID 25325033.
- ↑ Peterson PA, Cunningham BA, Berggård I, Edelman GM (1972). "2 -Microglobulin--a free immunoglobulin domain". Proc Natl Acad Sci U S A. 69 (7): 1697–701. doi:10.1073/pnas.69.7.1697. PMC 426781. PMID 4558655.
- ↑ Klein CJ, Moon JS, Mauermann ML, Zeldenrust SR, Wu Y, Dispenzieri A; et al. (2011). "The neuropathies of Waldenström's macroglobulinemia (WM) and IgM-MGUS". Can J Neurol Sci. 38 (2): 289–95. doi:10.1017/s0317167100011483. PMC 3901797. PMID 21320835.
- ↑ Levine T, Pestronk A, Florence J, Al-Lozi MT, Lopate G, Miller T; et al. (2006). "Peripheral neuropathies in Waldenström's macroglobulinaemia". J Neurol Neurosurg Psychiatry. 77 (2): 224–8. doi:10.1136/jnnp.2005.071175. PMC 2077569. PMID 16421127.
- ↑ Baldini L, Nobile-Orazio E, Guffanti A, Barbieri S, Carpo M, Cro L; et al. (1994). "Peripheral neuropathy in IgM monoclonal gammopathy and Wäldenstrom's macroglobulinemia: a frequent complication in elderly males with low MAG-reactive serum monoclonal component". Am J Hematol. 45 (1): 25–31. doi:10.1002/ajh.2830450105. PMID 7504399.