In the middle of 1983 a 40-year-old man presented with a one-month history of symptoms due to hyperviscosity. The etiology was Waldenstrom's macroglobulinemia. He was treated with three consecutive daily plasma exchanges, leading to prompt and complete reversal of the plasma abnormality and clinical symptoms. His underlying disease was managed on sequential hemibody radiotherapy in the form of 6Gy from a cobalt 60 unit at 160cm source-to-skin distance in a single fraction at a rate of 0.36 cGy/minute. Concurrent tuberculosis was treated and in the course of a year, using a standard 4-drug regimen, was cured.
During the same year the patient required intermittent plasma exchanges for recurrent hyperviscosity, and because of failure to eradicate the lymphoplasmacytoid infiltration in the bone marrow, the lower half of his body was re-treated on the radiotherapy schedule.
His initial response from May 1983 to October 1985 showed persistent disease in serial marrow trephine biopsies, but with a gradually rising hematopoietic reserve. Re-presentation with increasing immunoglobulin levels necessitated intermittent plasma exchanges [ 11.
In the subsequent five years, the patient returned his Karnofsky performance status to loo%, but in the middle of 1987 he presented with a hemoglobin of 44 g/L, lactic dehydrogenase of 599 i.u., total bilirubin of 38 pmol/L, of which 8 pmol/L was conjugated. Review of his records showed that macrocytosis had been present, together with decreased haptoglobins, for 18 months. A Coombs' positive warm antibody-mediated hemolytic anemia was diagnosed and the patient responded promptly to prednisone, at a dose of 1 mg/kg/day for 6 weeks, which was tapered off over the next 6 weeks. The episode resolved completely and all measurements were entirely normal by September 1987.
The patient was lost to follow-up between February 1988 and July 1988, but was apparently well and without any evidence of hemolysis.