PREMATURE DEATH DUE TO BLEENDING AND LEUKOSTASIS IN ACUTE MYELOID LEUKEMIA WITH UNUSUAL HYPERLEUKOCYTOSIS

Abstract

Hyperleukocytosis is defined as a leukocyte count greater than 100,000/mm in the peripheral blood and is more frequently observed in adults chronic lymphatic leukemias (CLL) and pediatric acute leukemia patients (1). Hyperleukocytosis in acute myeloid leukemia usually has lower values than those of CLL and is characterized by the presence in the peripheral blood of large immature cells (blasts), with a tendency to stack in small vessels. Compared to lymphoid blasts, myeloid blasts are larger, less deformable,and with a higher risk of manifesting hyperviscosity syndrome and the patients may also present with tumor lysis syndrome and disseminated intravascular coagulopathy. High-dose chemotherapy is is an emergency treatment that can reduce the risk of systemic consequences, whereas the role of leukapheresis is still debated (2, 3). Mortality may be 40% at 1 week and require urgent decisions for clinical management (1)

Here we report the case of a 69-year-old woman who came to the emergency room in June 2025 for fever and asthenia lasting for 3 days. The blood count documented GB 424x103/mmc, Hb 6.4 g/dl, platelets 20x103/mmc, K+ 2.84, CRP 3.4, BNP 1226, LDH 925 IU/I.
A few minutes after accessing the ER, the patient experienced sudden loss of consciousness and deterioration of the neurological picture with hemilate, was treated with catapresan for hypertensive crisis and transferred to the emergency room for intubation
The clinical picture was compatible with possible M4/M5 myeloid leukemia. A cerebral CT without contrast medium documented a significant intraparenchymal hemorrhage with subdural streaks and ventricular flooding. The rapidly evolving clinical picture did not allow for urgent treatment, so the patient underwent hydration therapy and transfusion of a platelet concentrate. In the case described, the rapid evolution of the clinical picture did not allow the activation neither leukpheresis, nor chemiotherapy treatmenbt and the patient died shortly after intubation.

In the case of significant leukocytosis, the treatment of hyperviscosity syndrome and possible coagulopathy requires the availability of rapid activation of therapeutic leukapheresis together with cytoreductive treatment, which must also be readily available for the emergency area.
To our knowledge, the case described documents the highest leukocyte count described in an adult subject with acute myeloid leukemia