Hyperviscosity syndrome
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Background
- Increased serum viscosity due to:
- Increased blood products (polycythemia, thrombocytosis, leukemia)
- Immunoglobulins (Waldenstrom's, IgA myeloma, multiple myeloma)
- Symptoms arise from poor capillary flow and organ congestion
Clinical Features
- General: fever, fatigue
- CNS: headache, blurred vision, altered mental status, focal neurologic deficits
- Pulm: dyspnea, hypoxia
- Cardiac: chest pain, CHF
- Heme: mucosal bleeding
Differential Diagnosis
Detailed differential can be found on each page
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
- Hypercalcemia of malignancy
- Hyponatremia due to SIADH
- Adrenal insufficiency
- Tumor lysis syndrome
- Carcinoid syndrome
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
Workup
- CBC, coags, type and screen, chem 10
- Urinalysis
- CT head if neuro symptoms
- CXR
- Consider initiating inpatient testing with: Total protein, albumin, SPEP, UPEP, IgA, IgG, IgM
- Note: ABGs might have SaO2 vs. SpO2 discrepancies
- Causing spurious hypoxemia on ABG, with low PaO2 (as opposed to dyshemoglobinemia)
- Due to "leukocyte larceny," "platelet larceny"[1][2][3]
- Excessive O2 consumption by WBCs or platelets following blood sample collection
Evaluation
Symptoms of hyperviscosity can appear when one of the following occur:
- Red cell mass > 25% of normal[4]
- Platelets >600,000/µL[5]
- Leukocytosis >100,000
- Serum viscosity >4-5cP (normal 1.4-1.8cP)[6] or Globulin gap (Total protein - albumin) > 4
Management
- ABCs
- IVF, supportive care
- Ig mediated
- Leukostasis
- Leukopheresis
- Thrombocytosis
- Plateletpheresis
- Consider ASA
- Polycythemia
- Phlebotomy
- If pheresis is not unavailable, phlebotomize 2-3 units, give 2-3 left IVF
Disposition
- Typically require admission if symptomatic
- Hem/Onc consult
See Also
External Links
References
- ↑ Mehta A, Lichtin AE, Vigg A, Parambil JG. Platelet larceny: spurious hypoxaemia due to extreme thrombocytosis. Eur Respir J. 2008 Feb;31(2):469-72.
- ↑ Sacchetti A, Grynn J, Pope A, Vasso S. Leukocyte larceny: spurious hypoxemia confirmed with pulse oximetry. J Emerg Med. 1990 Sep-Oct;8(5):567-9.
- ↑ Lele AV, Mirski MA, Stevens RD. Spurious hypoxemia. Crit Care Med. 2005 Aug;33(8):1854-6.
- ↑ Pearson TC and Messinezy M. The diagnostic criteria of polycythaemia rubra vera. Leuk Lymphoma. 1999; 22 (1):87-93.
- ↑ Murphy S et al. Diagnostic criteria and prognosis in polycythemia vera and essential thrombocythemia. Semin Hematol. 1999; 36(1):9-13.
- ↑ Mehta J and Singhal S. Hyperviscosity syndrome in plasma cell dyscrasias. Semin Thromb Hemost. 2003; 29(5):467-471.