Patients with high white blood counts and blast counts can present with symptoms of leukostasis secondary to hyperleukocytosis.3 Hyperleukocytosis is defined as a blast count of greater than 100,000/mm3 and occurs more commonly in patients with acute monocytic or myelomonocytic leukemia.2 4 A high early mortality is observed in patients with hyper-leukocytosis.2 With hyperleukocytosis, inelastic myeloblasts pack and plug blood vessels, leading to leukostasis and thrombus formation.12 Specific signs and symptoms can include shortness of breath, hypoxia, diffuse pulmonary infiltrates, headache, blurred vision, heart failure, myocardial infarction, and priapism.2,4,12 Leukostasis more commonly occurs with a rapidly rising blast count.12 Blasts can also invade and disrupt arterioles, leading to hemor-rhage.1219 Although there are no randomized controlled trials, patients with hyperleukocytosis should be leukapheresed to help bring the blast count down. Cytotoxic therapy should be initiated as soon as possible. If a definitive diagnosis has not been made, hydroxyurea can be used in conjunction with (or in place of) a pheresis until a diagnosis is made and definitive chemotherapy is started. A single dose of cranial radiation may also have some benefit in patients presenting with CNS symptoms and high white blood counts.1920 Patients with hyperleukocytosis should not be transfused with packed red cells until they have received appropriate cytoreductive treatment, since transfusion can increase blood viscosity and worsen symptoms.

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