Leukostasis and hyperleukocytosis: Difference between revisions

Latest revision as of 02:32, 11 January 2022

Background

Hyperleukocytosis is lab abnormality of WBC >50-100K
Blood viscosity increases
Leukostasis is symptomatic hyperleukocytosis; it is a medical emergency
- Most commonly seen with AML or CML in blast crisis
- High blast cell count > WBC plugs in microvasculature
  - Brain and lung are most commonly affected
20-40% of patients with leukostasis die within 1st week of presentation

Clinical Features

Fever
- 80% of patients
- May be due to inflammation associated with leukostasis or concurrent infection
Brain Leukostasis
- Headache
- Dizziness
- Tinnitus
- Visual disturbances
- Ataxia
- Confusion
- Stupor
- Coma
- Sudden death
Pulmonary Leukostasis
- Respiratory distress
- Hypoxemia
  - ABG may show falsely decreased PaO2; pulse oximetry is more accurate
- Respiratory failure

Differential Diagnosis

Oncologic Emergencies

Related to Local Tumor Effects

Malignant airway obstruction
Bone metastases and pathologic fractures
Malignant spinal cord compression
Malignant Pericardial Effusion and Tamponade
Superior vena cava syndrome

Related to Biochemical Derangement

Related to Hematologic Derangement

Related to Therapy

Chemotherapy-induced nausea and vomiting
Cytokine release syndrome
Chemotherapeutic drug extravasation
Differentiation syndrome (retinoic acid syndrome) in APML
Stem cell transplant complications
Catheter-related complications
- Tunnel infection
- Exit site infection
- CVC obstruction (intraluminal or catheter tip thrombosis)
- Catheter-related venous thrombosis
- Fracture of catheter lumen
- Oncologic therapy related adverse events

Evaluation

Work-Up

CBC
DIC labs
- DIC occurs in up to 40% of patients
- FDP, d-dimer, fibrinogen, coags
Tumor Lysis Syndrome labs
- TLS occurs in up to 10% of patients
- Chemistry
- Uric acid
- Calcium
- Phosphate

Evaluation

High degree of suspicion needed to make the diagnosis
WBC count usually >100K; can have symptoms with WBC as low as 50K
CXR
- Interstial or alveolar infiltrates

Management

Hyperleukocytosis (asymptomatic)
- Hydroxyurea may be all that is required
Leukostasis
- IV hydration
  - Prevent dehydration which can worsen condition
- Chemotherapy
  - Only treatment proven to improve survival
- Hydroxyurea + leukapheresis
  - Can be use for cytoreduction if chemo will be delayed
Allopurinol may help prevent Tumor lysis syndrome
Consider rasburicase
Broad spectrum antibiotics
- The leading cause of death in blast crisis is infection (patients are functionally neutropenic)

Disposition

Admit to ICU

References

Authors:

@@ Line 1: / Line 1: @@
-== Background  ==
+==Background==
+*Hyperleukocytosis is lab abnormality of WBC >50-100K
+*Blood viscosity increases
+*Leukostasis is symptomatic hyperleukocytosis; it is a medical emergency
+**Most commonly seen with [[AML]] or [[CML]] in blast crisis
+**High blast cell count > WBC plugs in microvasculature
+***Brain and lung are most commonly affected
+*20-40% of patients with leukostasis die within 1st week of presentation
-*Pathologic diagnosis where WBC plugs seen in microvasculature
+==Clinical Features==
-*High blast cell counts, blood viscosity is increased
+*[[Fever]]
-*Blood flow is slowed by aggregates of tumor cells, and the primitive leukemic cells are capable of invading through endothelium and causing hemorrhage
+**80% of patients
-*Usually seen in pts with AML, not seen in CML or CLL
+**May be due to inflammation associated with leukostasis or concurrent infection
-*WBC count usu &gt;100k, can happen as low as 50K
+*Brain Leukostasis
-*Brain and lung are most commonly affected
+**[[Headache]]
+**[[Dizziness]]
-== Clinical Features  ==
+**[[Tinnitus]]
+**[[Visual disturbances]]
+**[[Ataxia]]
+**[[Confusion]]
+**Stupor
+**[[Coma]]
+**Sudden death
+*Pulmonary Leukostasis
+**[[Respiratory distress]]
+**[[Hypoxemia]]
+***[[ABG]] may show falsely decreased PaO2; pulse oximetry is more accurate
+**[[Respiratory failure]]
-*Brain Leukostasis
+==Differential Diagnosis==
-**headache
+{{Oncologic emergencies DDX}}
-**stupor
-**dizziness
-**tinnitus
-**visual disturbances
-**ataxia
-**confusion
-**coma
-**sudden death
-*Pulmonary Leukostasis
+==Evaluation==
-**respiratory distress
+===Work-Up===
-**hypoxemia
+*CBC
-**respiratory failure
+*DIC labs
+**[[DIC]] occurs in up to 40% of patients
+**FDP, d-dimer, fibrinogen, coags
+*[[Tumor Lysis Syndrome]] labs
+**TLS occurs in up to 10% of patients
+**Chemistry
+**Uric acid
+**Calcium
+**Phosphate
-== Diagnosis  ==
+===Evaluation===
-*High degree of suspicion to make diagnosis
+*High degree of suspicion needed to make the diagnosis
-*WBC count usu &gt;100k, can happen as low as 50K + symptoms from tissue hypoxia
+*WBC count usually >100K; can have symptoms with WBC as low as 50K
-*CXR usu show interstial or alveolar infiltrates
+*[[CXR]]
+**Interstial or alveolar infiltrates
-== Treatment  ==
+==Management==
-*IV hydration to prevent dehydration that can worsen condition
+*Hyperleukocytosis (asymptomatic)
-*Avoid unnecessary transfusions
+**[[Hydroxyurea]] may be all that is required
-*Induction Chemo best treatment, improves survival
+*Leukostasis
-*Leukapheresis and Hydroxyurea can be use for cytoreduction while chemo being set up
+**IV hydration
+***Prevent dehydration which can worsen condition
+**Chemotherapy
+***Only treatment proven to improve survival
+**[[Hydroxyurea]] + leukapheresis
+***Can be use for cytoreduction if chemo will be delayed
+*[[Allopurinol]] may help prevent [[Tumor lysis syndrome]]
+*Consider [[rasburicase]]
+*Broad spectrum [[antibiotics]]
+**The leading cause of death in blast crisis is infection (patients are functionally [[neutropenia|neutropenic]])
-== Disposition  ==
+==Disposition==
 *Admit to ICU
-== Source  ==
+==References==
-Harrison's Internal Medicine Oncologic Emergencies & Uptodate
+<references/>
 [[Category:Heme/Onc]]