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Catastrophic thromboembolism in a patient with acute lymphoblastic leukemia and hypereosinophiliaEileen Williams, Steven C. Smart, Ronald S. Go,
Section of Hematology/Medical Oncology, Section of Cardiology, Division of Internal Medicine, Gundersen Lutheran Medical Center, La Crosse, Wisconsin
Correspondence: Ronald S. Go, M.D.
Gundersen Lutheran Medical Center, Section of Hematology, East Building, 1900 South Avenue, La Crosse, Wisconsin, U.S.A. 54601
Phone: (608) 775-2139, Fax: (608) 775-6627
A 20-year-old man was diagnosed with precursor B-cell acute lymphoblastic leukemia (ALL) associated with hypereosinophilia. His peripheral blood showed a total white count of 30.5 x 109 /L with 49% blasts and 35% eosinophils. While receiving induction chemotherapy consisting of daunorubicin, vincristine, prednisone, and L-asparaginase, the patient developed multiple upper extremity deep venous thrombi (DVTs). Despite heparin anticoagulation and discontinuation of L-asparaginase, progressive DVTs involving both common femoral veins occurred. Due to the concurrent development of anasarca, a transthoracic echocardiogram was performed. It revealed multiple intraventricular masses consistent with thrombi (Figure 1). He then experienced left upper quadrant pain and numbness of the right lower extremity. A subsequent computed tomographic scan of the chest, abdomen, and pelvis demonstrated stable ventricular thrombi (Figure 2), a new large splenic infarct (Figure 3), and a new embolus at the aortic bifurcation (Figure 4). When the patient developed acute shortness of breath from a pulmonary embolus, an emergency biventricular embolectomy was successfully performed.
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Hypereosinophilia in the setting of ALL is rare. The patient described here demonstrates that cardiac and peripheral vascular thrombi can occur in this condition. Previous case studies involving patients with ALL with associated eosinophilia showed increased morbidity, specifically heart disease, compared to patients with only ALL. It is also possible that L-asparaginase played a synergistic role in the development of this patient’s multiple thromboemboli. Our case suggests that L-asparaginase be used cautiously when hypereosinophilia is present in the setting of ALL. If L-asparaginase is to be used, aggressive prophylactic anticoagulation should be considered .
Legends
Figure 1. Transthoracic echocardiogram demonstrating multiple left ventricular thrombi.
Figure 2. Computed tomographic scan demonstrating biventricular thrombi.
Figure 3. Computed tomographic scan demonstrating a large splenic infarct.
Figure 4. Computed tomographic scan demonstrating an embolus at the aortic bifurcation.
References
1. Fishel RS, Farnen JP, Hanson CA, Silver SM, Emerson SG. Acute lymphoblastic leukemia with eosinophilia. Medicine 1990:69, 232-43.
