Hyperviscosity Syndrome Workup

  • Author: Thomas J Hemingway, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP   more...
 
Updated: Apr 10, 2012
 

Laboratory Studies

  • Determine serum viscosity.
    • Serum viscosity is diagnostic in evaluating hyperviscosity syndrome when the elevated viscosity is concomitant with characteristic symptoms. No exact diagnostic cut-off exists for viscosity as different patients will have symptoms at different values of viscosity.
    • A clue may be that the laboratory may be having difficulty performing chemical tests on the blood due to the serum stasis and increased viscosity, which may clog analyzers.
    • The normal reference range is 1.4-1.8 Centipoises (1.0 being the viscosity of water).
    • Symptoms usually are not seen before the viscosity reaches 4 Centipoises, and hyperviscosity syndrome usually presents with a serum viscosity greater than 5 Centipoises. Typically, the higher the viscosity, the worse are the symptoms.
  • Obtain a peripheral blood smear with the CBC. Rouleaux formation is often present with increased serum viscosity.
  • WBC count is typically 100,000 or greater in leukostasis causing HVS, but it may be lower in the blast crises of the leukemias.
  • Consider adding total protein (TP) and albumin as in the paraproteinemias; a globulin gap (TP – albumin = 4 or greater) may exist.
  • Consider adding a metabolic panel and electrolytes as derangements such as hypercalcemia, hyperphosphatemia, and hyperkalemia are common and may require specific treatment. (Be sure not to contribute to pseudohyperkalemia secondary to the increased cellular lysis from poor venipuncture technique; use a larger needle, withdraw slowly and, if in doubt, send for a plasma rather than serum potassium level, which will be more reliable).
  • Consider adding serum and urine electrophoresis in new cases without preceding diagnosis for diagnostic purposes.
  • Consider coagulopathy workup (eg, blood count, type and screen, prothrombin time, activated partial thromboplastin time, platelet count) if the patient presents with hemorrhage.
  • Tailor additional workup (eg, chest radiography, brain CT or MRI) to the patient's presentation.
  • Consider panculture and urinalysis.
    • Multiple myeloma is complicated frequently by infections.
    • In nonneutropenic patients, infections are usually secondary to Streptococcus pneumoniae or Haemophilus influenzae.
  • Search for other disorders. Hyperviscosity syndrome is the result of another pathologic process (eg, multiple myeloma, Waldenström macroglobulinemia, hyperproliferative blood cell dysplasias).
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Imaging Studies

  • Head CT scan is indicated if the patient presents with altered level of consciousness, seizures, or focal neurologic deficits.
  • Contrast dye is contraindicated in multiple myeloma because of the increased risk of renal failure.
  • Chest radiograph may be indicated to rule out infection. It also may reveal congestive heart failure (CHF). High output failure can be caused by hyperviscosity or anemia.
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Contributor Information and Disclosures
Author

Thomas J Hemingway, MD  Attending Physician, Department of Emergency Medicine, Wilcox Memorial Hospital

Thomas J Hemingway, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Eric Alexander Savitsky, MD  Associate Clinical Professor of Medicine, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles Medical Center

Eric Alexander Savitsky, MD is a member of the following medical societies: Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Douglas F Kupas, MD  Associate Chief Academic Officer, Geisinger Health System; Assistant Dean for Medical Student Affairs, Temple University Geisinger Clinical Campus; Commonwealth EMS Medical Director, Pennsylvania Department of Health

Douglas F Kupas, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Robin R Hemphill, MD, MPH  Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University School of Medicine

Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jeffrey L Arnold, MD, FACEP  Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center

Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physicians

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. Behl D, Hendrickson AW, Moynihan TJ. Oncologic emergencies. Crit Care Clin. Jan 2010;26(1):181-205. [Medline].

  2. Adams BD, Baker R, Lopez JA, Spencer S. Myeloproliferative disorders and the hyperviscosity syndrome. Emerg Med Clin North Am. Aug 2009;27(3):459-76. [Medline].

  3. Blade J, Rosinol L. Complications of multiple myeloma. Hematol Oncol Clin North Am. Dec 2007;21(6):1231-46, xi. [Medline].

  4. Bloch KJ, Maki DG. Hyperviscosity syndromes associated with immunoglobulin abnormalities. Semin Hematol. Apr 1973;10(2):113-24. [Medline].

  5. Blum W, Porcu P. Therapeutic apheresis in hyperleukocytosis and hyperviscosity syndrome. Semin Thromb Hemost. Jun 2007;33(4):350-4. [Medline].

  6. D'Alessio T, Kupas DF. Altered mental status in a 57-year-old woman with multiple myeloma. Top Emerg Med. 1996;18(2):72-8.

  7. Drew MJ. Plasmapheresis in the dysproteinemias. Ther Apher. Feb 2002;6(1):45-52. [Medline].

  8. Fahey JL, Barth WF, Solomon A. Serum hyperviscosity syndrome. JAMA. May 10 1965;192:464-7. [Medline].

  9. Gertz MA, Kyle RA. Hyperviscosity syndrome. J Intensive Care Med. May-Jun 1995;10(3):128-41. [Medline].

  10. Higdon ML, Higdon JA. Treatment of oncologic emergencies. Am Fam Physician. Dec 1 2006;74(11):1873-80. [Medline].

  11. Hoffman R, et al. Therapy. In: Meloni D, Cox KJ, eds. Hematology: Basic Principles and Practice. 4th ed. Philadelphia, Pa: Elsevier, Churchill, Livingstone; 2005.

  12. Hussein M. Multiple myeloma: an overview of diagnosis and management. Cleve Clin J Med. Jul-Aug 1994;61(4):285-98. [Medline].

  13. Kwaan HC, Bongu A. The hyperviscosity syndromes. Semin Thromb Hemost. 1999;25(2):199-208. [Medline].

  14. Kyle RA. Multiple myeloma: review of 869 cases. Mayo Clin Proc. Jan 1975;50(1):29-40. [Medline].

  15. Mehta J, Singhal S. Hyperviscosity syndrome in plasma cell dyscrasias. Semin Thromb Hemost. Oct 2003;29(5):467-71. [Medline].

  16. Ovadia S, Lysyy L, Floru S. Emergency plasmapheresis for unstable angina in a patient with hyperviscosity syndrome. Am J Emerg Med. Oct 2005;23(6):811-2. [Medline].

  17. Rogers R. Emergencies in Hematology and Oncology - Subtle and Atypical presentations, pearls and pitfalls. EMedHome.com [web site].

  18. Rosen P, et al. Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice. 5th ed. Mosby Inc; 2002.

  19. Stone MJ, Bogen SA. Evidence-based focused review of management of hyperviscosity syndrome. Blood. Mar 8 2012;119(10):2205-8. [Medline].

  20. Zarkovic M, Kwaan HC. Correction of hyperviscosity by apheresis. Semin Thromb Hemost. Oct 2003;29(5):535-42. [Medline].

 
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