Journal of Blood Medicine (Dec 2023)
Hyperviscosity Syndrome Induced Bilateral Visual and Auditory Impairment in Therapy Resistant Waldenström Macroglobulinemia with MYD88 and CXCR4 Mutations
Abstract
Marie M Plante,1 ErinMarie O Kimbrough,2 Amit K Agarwal,3 Liuyan Jiang,4 Kirk Bourgeois,4 Greta C Stamper,5 Michael W Stewart,6 Han W Tun2 1Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA; 2Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL, USA; 3Department of Radiology, Mayo Clinic, Jacksonville, FL, USA; 4Department of Pathology, Mayo Clinic, Jacksonville, FL, USA; 5Department of Otolaryngology and Audiology, Mayo Clinic, Jacksonville, FL, USA; 6Department of Ophthalmology, Mayo Clinic, Jacksonville, FL, USACorrespondence: Han W Tun, Division of Hematology and Oncology, Mayo Clinic, 4500 San Pablo Road S, Jacksonville, FL, USA, Tel +1 904 953 7290, Fax +1 904 953 2315, Email [email protected]: Hyperviscosity syndrome (HVS) is an emergent complication of Waldenström macroglobulinemia (WM) characterized by visual, neurologic, and rarely auditory impairment. We report a 69-year-old female with MYD88 and CXCR4-mutant WM who developed HVS resulting in bilateral blindness and deafness associated with neurologic manifestations including confusion, severe generalized weakness, and imbalance. Ophthalmologic evaluation revealed bilateral central retinal vein occlusion (CRVO), diffuse retinal hemorrhages, macular edema, and serous macular detachments (SMD). Magnetic resonance imaging of the brain showed bleeding in the inner ears. Management was challenging as her WM was resistant to systemic therapies including bendamustine + rituximab (BR) and rituximab + bortezomib + dexamethasone (RVD). Bruton’s tyrosine kinase inhibitors could not be used initially due to ongoing lower gastrointestinal bleeding. She required five total sessions of plasma exchange and was finally initiated on zanubrutinib, achieving a partial response. She also received intravitreal bevacizumab with rapid resolution of the retinal hemorrhages but with little improvement of the SMD. She had partial restoration of her hearing in the right ear and only slight improvement in her bilateral visual deficits. The management of HVS in frail, elderly patients with therapy-resistant WM can be challenging. In these cases, plasma exchange is required until an effective systemic therapy can be safely instituted. Genomic profiling is important in the management of WM as it can predict treatment resistance and guide therapeutic decisions.Keywords: hyperviscosity syndrome, Waldenström macroglobulinemia, central retinal vein occlusion, exudative maculopathy, serous macular detachment, cochlear hemorrhage, plasma exchange, genomic sequencing, CXCR4
