Acute Blast Crisis/Hyperviscosity Syndrome: Blasting Off!

  • Colin G. Kaide
  • Geremiha EmersonEmail author


Emergency providers are likely to encounter patients with acute and chronic leukemias. The first presentation to the ED may be for symptoms related to blast crisis and leukostasis. Making a timely diagnosis and immediately consulting a hematologist can be life-saving. Presenting symptoms are due to complications of bone marrow infiltration and hyperleukocytosis with WBC counts over 100,000. Presentations may include fatigue (anemia), bleeding (thrombocytopenia), shortness of breath, and/or neurological symptoms owing to hyperleukocytosis and subsequent leukostasis. Blast crisis with leukostasis is a Heme/Onc emergency. Treatment of symptomatic cases involves induction chemotherapy and/or leukapheresis. Asymptomatic hyperleukocytosis can be treated with hydroxyurea.


Blast Leukstasis Leukapheresis Petechiae Hyperviscosity Chronic myeloid leukemia (CML) Acute myeloid leukemia (AML) Hydroxyurea 


Disclosure Statement

Geremiha Emerson has no disclosures. Colin Kaide: Callibra, Inc.-Discharge 123 medical software company. Medical Advisory Board Portola Pharmaceuticals. I have no relationship with a commercial company that has a direct financial interest in subject matter or materials discussed in article or with a company making a competing product.


  1. 1.
    Vardiman JW, Harris NL, Brunning RD. The World Health Organization (WHO) classification of the myeloid neoplasms. Blood. 2002;100(7):2292–302.CrossRefGoogle Scholar
  2. 2.
    Dutcher JP, Schiffer CA, Wiernik PH. Hyperleukocytosis in adult acute nonlymphocytic leukemia: impact on remission rate and duration, and survival. J Clin Oncol. 1987;5(9):1364–72.CrossRefGoogle Scholar
  3. 3.
    Canaani J, et al. Long term impact of hyperleukocytosis in newly diagnosed acute myeloid leukemia patients undergoing allogeneic stem cell transplantation: an 9analysis from the acute leukemia working party of the EBMT. Am J Hematol. 2017;92(7):653–9.CrossRefGoogle Scholar
  4. 4.
    Jabbour E, Kantarjian H. Chronic myeloid leukemia: 2014 update on diagnosis, monitoring, and management. Am J Hematol. 2014;89(5):547–56.CrossRefGoogle Scholar
  5. 5.
    Lichtman MA. Rheology of leukocytes, leukocyte suspensions, and blood in leukemia possible relationship to clinical manifestations. J Clin Invest. 1973;52(2):350–8.CrossRefGoogle Scholar
  6. 6.
    Lichtman MA, Weed RI. Peripheral cytoplasmic characteristics of leukocytes in monocytic leukemia: relationship to clinical manifestations. Blood. 1972;40(1):52–61.CrossRefGoogle Scholar
  7. 7.
    Schiffer CA, Wiernik PH. Functional evaluation of circulating leukemic cells in acute non-lymphocytic leukemia. Leuk Res. 1977;1(4):271–7.CrossRefGoogle Scholar
  8. 8.
    Stucki A, Rivier AS, Gikic M, et al. Endothelial cell activation by myeloblasts: molecular mechanisms of leukostasis and leukemic cell dissemination. Blood. 2001;97:2121.CrossRefGoogle Scholar
  9. 9.
    Porcu P, et al. Hyperleukocytic leukemias and leukostasis: a review of pathophysiology, clinical presentation and management. Leuk Lymphoma. 2000;39(1–2):1–18.CrossRefGoogle Scholar
  10. 10.
    Perazella MA, et al. Renal failure and severe hypokalemia associated with acute myelomonocytic leukemia. Am J Kidney Dis. 1993;22(3):462–7.CrossRefGoogle Scholar
  11. 11.
    Awh CC, et al. Leukostasis retinopathy: a new clinical manifestation of chronic myeloid leukemia with severe hyperleukocytosis. Ophthalmic Surg Lasers Imaging Retina. 2015;46(7):768–70.CrossRefGoogle Scholar
  12. 12.
    Ali AM, et al. Leukostasis in adult acute hyperleukocytic leukemia: a clinician’s digest. Hematol Oncol. 2016;34(2):69–78.CrossRefGoogle Scholar
  13. 13.
    Bellevue R, et al. Pseudohyperkalemia and extreme leukocytosis. J Lab Clin Med. 1975;85(4):660–4.PubMedGoogle Scholar
  14. 14.
    Karp DD, Beck JR, Cornell CJ. Chronic granulocytic leukemia with respiratory distress: efficacy of emergency leukapheresis. Arch Intern Med. 1981;141(10):1353–4.CrossRefGoogle Scholar
  15. 15.
    Lane TA. Continuous-flow leukapheresis for rapid cytoreduction in leukemia. Transfusion. 1980;20(4):455–7.CrossRefGoogle Scholar
  16. 16.
    Eisenstaedt RS, Berkman EM. Rapid cytoreduction in acute leukemia: management of cerebral leukostasis by cell pheresis. Transfusion. 1978;18(1):113–5.CrossRefGoogle Scholar
  17. 17.
    Bug G, et al. Impact of leukapheresis on early death rate in adult acute myeloid leukemia presenting with hyperleukocytosis. Transfusion. 2007;47(10):1843–50.CrossRefGoogle Scholar
  18. 18.
    Giles FJ, et al. Leukapheresis reduces early mortality in patients with acute myeloid leukemia with high white cell counts but does not improve long term survival. Leuk Lymphoma. 2001;42(1–2):67–73.CrossRefGoogle Scholar
  19. 19.
    Ganzel C, et al. Hyperleukocytosis, leukostasis and leukapheresis: practice management. Blood Rev. 2012;26(3):117–22.CrossRefGoogle Scholar
  20. 20.
    Ruggiero A, et al. Management of hyperleukocytosis. Curr Treat Options in Oncol. 2016;17(2):7.CrossRefGoogle Scholar
  21. 21.
    Harris AL. Leukostasis associated with blood transfusion in acute myeloid leukaemia. Br Med J. 1978;1(6121):1169–71.CrossRefGoogle Scholar
  22. 22.
    Grund FM, Armitage JO, Patrick Burns C. Hydroxyurea in the prevention of the effects of leukostasis in acute leukemia. Arch Intern Med. 1977;137(9):1246–7.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of Emergency Medicine, Wexner Medical Center at The Ohio State UniversityColumbusUSA

Personalised recommendations