Fatal Acute Right Heart Failure Due to Leukostasis in Acute Lymphoblastic Leukemia with Hyperleukocytosis

Document Type

Conference Proceeding

Publication Date

5-2026

Publication Title

American Journal of Respiratory and Critical Care Medicine

Abstract

Leukostasis is a known life-threatening complication of hyperleukocytosis from hematologic malignancies. Leukostasis occurs when blasts accumulate in the vasculature causing hyperviscosity and microvascular occlusion; this can lead to multi-organ complications including respiratory compromise. While well-described in patients with acute myeloid leukemia (AML), it is rarely seen in patients with acute lymphocytic leukemia. We present a case of a patient with acute lymphoblastic leukemia presenting with leukostasis resulting in cardiac arrest.

A 61-year-old female with a past medical history of Philadelphia chromosome-positive acute lymphoblastic leukemia presented to the emergency department with dyspnea and abdominal pain. She was found to have a white blood cell (WBC) count of 395,100/µl with 92% blasts. Computed tomography (CT) angiography of the thorax showed no evidence of pulmonary embolism or other acute pathology. Treatment was initiated with hydroxyurea and prednisone. Several hours after admission, the patient had an atraumatic syncopal episode while in the bathroom. After regaining consciousness, the patient was assisted back into bed and developed significantly increased work of breathing. Shortly after, she became unresponsive and pulseless. Resuscitative efforts with advanced cardiac life support were performed for cardiac arrest with pulseless electrical activity. After return of circulation, the patient was in profound shock requiring three vasopressors with worsening hypoxia. An echocardiogram showed a small, hyperdynamic left ventricle, systolic septal flattening consistent with right ventricle (RV) pressure overload, and a severely dilated right ventricle with severely reduced systolic function, most prominently along the mid-apical RV free wall. The patient was too unstable for repeat CT imaging. Laboratory results showed that the patient’s WBC count had further increased to 464,600/µl with 96% blasts. She developed progressive coagulopathy and spontaneous bleeding consistent with disseminated intravascular coagulation. Emergent leukapheresis was initiated, however, the patient became progressively more hypotensive despite maximum support and died. Given the recent negative CT angiography, the patient’s cardiac arrest, respiratory failure, and subsequent death were thought to be due to acute right sided heart failure secondary to pulmonary leukostasis.

Hyperleukocytosis can lead to respiratory distress by accumulation of blasts in the pulmonary microvasculature. Although hyperleukocytosis is seen with multiple hematologic malignancies, leukostasis is more commonly seen in AML because the myeloid blasts are less deformable and thus more likely to occlude the vasculature. Although it is rare for acute lymphoid leukemias to present with leukostasis, due to the severity of this phenomenon, it is important to consider in patients with hyperleukocytosis.

Volume

212

Issue

Suppl 1

First Page

S1093

Last Page

S1093

Comments

American Thoracic Society International Conference, May 15-20, 2026, Orlando, FL

DOI

10.1093/ajrccm/aamag162.1454

ISSN

1073-449X

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