Case Presentation
A man in his early 40s with no past medical history presented to the
emergency department with three days of left eye pain and associated
worsening blurry vision. He was initially evaluated at a local optometry
clinic and found to have retinal hemorrhages with decreased visual
acuity and a central retinal vein occlusion (Figure 1) and
referred to the emergency department. At the time of initial
presentation, he complained of a white spot that obscured his vision. He
also endorsed loss of appetite for one week without weight loss. He
denied fevers, chills, night sweats, or a personal or family history of
cancer. He was hemodynamically stable. Pertinent physical exam findings
were hepatomegaly and splenomegaly.
Initial laboratory values were significant for leukocytosis of 477
K/cumm with 10% blasts, 4% basophils, 4% eosinophils, and platelets
of 276 K/cumm. Computed tomography imaging was notable for hepatomegaly
and a markedly enlarged spleen with mass effect on the organs of the
left hemi-abdomen. Bone marrow biopsy was performed with results
indicating marked leukocytosis and circulating blasts of 7%. BCR-ABL
genetic test was obtained and was positive, confirming the diagnosis of
CML.
A femoral central venous catheter was placed and the patient was
initiated on leukapheresis on day one of admission. He was given three
grams of hydroxyurea in the emergency department and then started on
hydroxyurea two grams twice a day. White blood count initially increased
to 533 K/cumm and 487 K/cumm after leukapheresis. Over the course of his
hospitalization, his visual symptoms improved after leukapheresis with
nearly total improvement of his left visual deficits within two days.
His leukocytosis began to resolve in the days following leukapheresis,
initially decreasing to 340 K/cumm the day after the procedure and
decreased to 245 K/cumm on hospital day four.
The patient was discharged on hospital day four with two grams of
hydroxyurea three times a day for two weeks with planned hematology
follow-up and initiation of a tyrosine kinase inhibitor.
Two weeks after, ophthalmologic photos were obtained demonstrating
improvement of the central retinal vein occlusion, intraretinal
hemorrhages, and cotton wool spots (Figure 2). At follow-up two
years after initial presentation, the patient remains on maintenance
dasatinib with no permanent vision changes.