Multiple flesh-colored papules on the waist and multiple purpuric nodules on the tongue

Abstract

An 83-year-old man presented with a 1-month history of multiple flesh-colored waxy papules over his bilateral waist, and bilateral inguinal and suprapubic areas. He had also noted multiple blister-like nodules over his buccal mucosa and various-sized purpuric tumors on his tongue for over a year. Both types of lesions were asymptomatic. His medical history included hypertension, chronic renal insufficiency, and previous cerebrovascular accident, and he was regu-larly followed up at our hospital. There was no relevant family history and no constitutional symptoms, except for a 1-month history of right hip and right shoulder pain.Two skin biopsy specimens were obtained from the ab-domen and lip. Histopathologic examination of the ab-dominal papule revealed a large amount of pink amorphous deposits in the superficial dermis. Histopathologic exami-nation of the lip showed similar deposits in the submucosa and small vessel walls. Congo red staining of both speci-mens revealed green birefringence under polarized light.Protein electrophoresis revealed a pattern indicative of monoclonal gammopathy, with a spike in the beta region. Immunofixation electrophoresis of blood and urine disclosed IgA-lambda paraprotein and lambda light chain parapro-tein, respectively. Biopsy results from the bone marrow re-vealed sheets of plasma cells, including some immature forms, and occasional Dutcher bodies. The plasma cells accounted for up to 70% of all nucleated cells focally. No evidence of bone or renal involvement was found in skull X-ray or renal echo examinations. However, magnetic reso-nance imaging of the heart revealed abnormal thickening and akinesia of the septal wall of the left ventricle.