Uncontrolled and Recurrent Epistaxis in an Adult: The Globulin Gap Clue

Abstract

A 49-year-old man presented with recurrent epistaxis, gingival bleeding, vertigo, and severe anemia. Despite normal coagulation parameters, bleeding worsened after red blood cell transfusion and was refractory to standard therapy. A marked globulin gap on routine liver function testing raised suspicion of paraproteinemia. Retinal hemorrhages and rapid symptom resolution following plasmapheresis confirmed hyperviscosity syndrome. Further evaluation established a diagnosis of immunoglobulin M-kappa Waldenström macroglobulinemia. This case highlights the importance of recognizing an elevated globulin gap as a simple clue to underlying paraproteinemia and hyperviscosity in patients with unexplained mucosal bleeding.