The plot thickens

• Multiple myeloma is occasionally associated with HVS, which manifests with mucosal bleeding, blurred vision, and headache.
• Hyperviscosity angina—cardiac ischemia resulting from poor coronary perfusion caused by hyperviscous blood—should be considered in patients with paraproteinemias and chest pain.
• Plasmapheresis reverses the clinical manifestations of HVS but not the underlying disease process (eg, Waldenström’s macroglobulinemia, multiple myeloma, leukemia, polycythemia).
• Spontaneous echo contrast represents increased RBC aggregation, from interaction of RBCs and plasma proteins, at low shear rates, and is associated with left atrial stasis, commonly from atrial fibrillation or mitral stenosis, but might be present in HVS.

Acknowledgment

The authors thank Peter Campochiaro, MD, and Whitney Green, MD, for their contributions to the images used in this article.

Disclosure

Dr. Sedighi Manesh is supported by the Jeremiah A. Barondess Fellowship in the Clinical Transaction of the New York Academy of Medicine, in collaboration with the Accreditation Council for Graduate Medical Education (ACGME). The other authors have nothing to report.