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3. Acute Blast Crisis/Hyperviscosity Syndrome: Blasting Off!
Keywords
BlastLeukstasisLeukapheresisPetechiaeHyperviscosityChronic myeloid leukemia (CML)Acute myeloid leukemia (AML)HydroxyureaCase
Pertinent History
This patient is a 74-year-old male who presented to the Emergency Department at 0800 with 5 days of shortness of breath, nonproductive cough, and generalized fatigue. He denied any associated fevers/chills, abdominal pain, nausea, vomiting, dysuria, melena, or hematochezia. He does note a diffuse non-pruritic rash.
PMH
Hypertension, hyperlipidemia
Meds: Amlodipine, Simvastatin
SH
Smoker (1 PPD × 20 years), denies alcohol or drug use
Pertinent Physical Exam
BP 135/60, Pulse 102, RR 24, SpO2 90% (RA), Temperature 98.7 °F (37.1 °C)Except as noted below, the findings of a complete physical exam are within normal limits.
General: Awake and alert. Appears uncomfortable and frail.
Cardiovascular: Tachycardic with regular rhythm. No rubs, gallops or murmurs. Sluggish capillary refill. No peripheral edema.
Pulmonary: Tachypnea with increased work of breathing. Diffuse rhonchi and faint wheezing appreciated in all fields.
Integument: Diffuse petechial rash.
Petechiae
Published with kind permission of © Colin G. Kaide 2019. All Rights Reserved
Pertinent Diagnostic Testing
Chest X-ray
Interstitial infiltrates suggestive of pulmonary edema. Bilateral peri-bronchovascular infiltrates in the bilateral lower lung zones.
Published with kind permission of © Colin G. Kaide 2019. All Rights Reserved
ECG
Sinus tachycardia. Normal axis and intervals. No concerning ST segment or T-wave changes.
Plan
Update 1 (0900): The patient showed some modest improvement in his respiratory status with the noninvasive PPV. He continues to remain tachycardic and afebrile, and as such antimicrobials were held. Laboratory tests were slow to return, which the technicians attributed to multiple abnormal levels.
Update 2 (1015): The patient remained stable with ongoing shortness of breath and mild tachycardia. Labs returned (see below), and many show marked abnormalities, including marked leukocytosis, thrombocytopenia, critical hyperkalemia, and AKI.
Cardiac markers returned within normal limits. Concerns were raised for an acute hematologic malignancy, and arrangements are made for transfer to a nearby cancer center. Given concerns for pulmonary edema, IV fluids were withheld, as were antibiotics, given the absence of infectious symptoms. The patient is given insulin + dextrose for the hyperkalemia.
Lab Results | |||
|---|---|---|---|
Test | Results | Units | Normal range |
WBC | 160 | K/uL | 3.8–11.0 103/mm3 |
HGb | 11.6 | g/dL | (Male) 14–18 g/dL (Female) 11–16 g/dL |
Platelets | 62 | K/uL | 140–450 K/uL |
BUN | 26 | mg/dL | 6–23 mg/dL |
Creatinine | 2.29 | mg/dL | 0.6–1.5 mg/dL |
Potassium | >10 | mEq/L | 3.5–5.5 mEq/L |
Lactate | 2.5 | mmol/L | <2.0 |
LDH | 1490 | U/L | 50–150 U/L |
Uric Acid | 11.6 | mg/dL | (3.5–7.7 mg/dL) |
Troponin | <0.01 | ng/dl | < 0.04 |
BNP | 60 | pg/ml | <100 |
INR | 1.6 | – | ≤ 1.1 |
Update 3 (1230): Patient leaves ED as a transfer to the cancer center. Shortly thereafter, a critical alert is called by the lab, reporting that the differential includes >85% blast cells.
Learning Points: Acute Blast Crisis and Leukostasis
Priming Questions
- 1.
What is a blast crisis and in which type of leukemia patients can it develop?
- 2.
What is Leukostasis and how does it manifest clinically?
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