Clinical features and presentation

• Occasional diagnosis following routine ESR/PV/FBC/blood film.

• Usually insidious onset of weakness and fatigue.

• Often present with symptoms of anaemia, epistaxis, recurrent infection, dyspnoea, CCF and weight loss.

• Usually no bone pain and no evidence of destructive bone disease.

• Symptoms of hyperviscosity (headache, dizziness, visual upset, bleeding, ataxia, CCF and somnolence, stupor and coma) 15-20%.

• Peripheral neuropathy—usually sensory or sensorimotor (~20%): distal, symmetrical, slowly progressive, usually lower extremities.

• Hepatomegaly (~25%); splenomegaly and lymphadenopathy less frequent.

• Fundoscopy reveals distended sausage-shaped veins, retinal haemorrhage ± papilloedema.

• Cryoglobulinaemia (<5%) may cause Raynaud's syndrome, arthralgia, purpura, peripheral neuropathy, liver dysfunction and renal failure.

• Haemorrhagic symptoms (e.g. epistaxis or easy bruising) may develop as a result of abnormalities of platelet function or coagulation due to the paraprotein.

• Amyloidosis may occur (<5%) causing cardiac, renal, hepatic or pulmonary dysfunction or macroglossia.

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