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Multiple purpuric nodules on the tongue
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 regularly 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 abdomen and lip. Histopathologic examination of the abdominal papule revealed a large amount of pink amorphous deposits in the superficial dermis. Histopathologic examination of the lip showed similar deposits in the submucosa and small vessel walls. Congo red staining of both specimens 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 paraprotein, respectively. Biopsy results from the bone marrow revealed 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 resonance imaging of the heart revealed abnormal thickening and akinesia of the septal wall of the left ventricle.


fig 1
Multiple flesh-colored papules on the waist


fig 2
Multiple purpuric nodules on the tongue

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