Ring of fire cells: plasma cell–predominant relapse of Waldenström macroglobulinemia

A B CA 74-year-old man with Waldenstrm macroglobulinemia (WM), previously treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone), presented 2 years later with symptomatic anemia, rising IgM (6000 mg/ dL), and an elevated / ratio of 3.04.Bone marrow aspirate revealed 20% plasma cell infiltration with a bright reddish cytoplasmic hue, characteristic of flame cells (panels A-C: Wright-Giemsa stain, oil immersion; panels A and B, 100 lens objective; panel C, 40 lens objective).Immunophenotyping demonstrated a 21% clonal plasma cell population expressing CD38, CD138, and cytoplasmic kappa light chain restriction, with retained expression of CD19, CD45, CD27, and CD81, and absence of CD56 and CD117.Unlike at diagnosis, no plasmacytoid lymphocytes or clonal B lymphocytes were identified by morphology or immunophenotype.