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.