CORRESPONDENCE Hyperleukocytosis: Emergency Management : Authors’ Reply Deepak Bansal & Richa Jain Received: 23 April 2013 / Accepted: 8 May 2013 # Dr. K C Chaudhuri Foundation 2013 To the Editor: We thank Gupta et al. for their comments. In a patient with acute leukemia, hyperleukocytosis and Hb >7 g/dL, hydration is initiated at 2–4 times of normal maintenance. Leukoreduction by either leukapheresis or exchange transfusion is considered if the patient has symp- toms related to leukostasis. If an exchange transfusion is planned, recommended volume varies from 70 to 150 mL/kg, as mentioned in the article [1]. Exchange transfusion can be performed with whole blood or with a mix of packed red blood cells and plasma (in a ratio of 2–3:1). One may prefer a lower concentration of packed red cells (say 2:1, instead of 3:1) in a child with a higher Hb, compared to a very anemic child. The decision may be individualized. It has been rightly pointed that hydroxyurea (HDU) has been used as a cytoreductive agent, typically in chronic myeloid leukemia (CML) and acute myeloid leukemia (AML). Its use appears to be less popular in pediatric as compared to the adult hematology services. HDU would not need to be considered in a patient with acute lymphoblastic leukemia, as rapid cytoreduction can successfully be achieved with steroid monotherapy in the large majority. It has been reported that HDU 50–100 mg/kg per day, given orally in 3–4 divided doses, reduces the WBC count by 50 % to 80 % within 24–48 h without causing tumor lysis pneumopathy or worsening the disseminated intravascular coagulation [2]. According to Porcu et al. it should be started immediately in all patients with hyperleukocytic AML and continued until more definitive che- motherapy is initiated [3]. HDU has a definitive role in CML. Leukemoid reaction severe enough to cause hyperleukocytosis is very rarely encountered and reported in literature. Exchange transfusion has been recommended in the setting of pertussis pneumonia with hyperleukocytosis and pulmonary hypertension [4]. In a case report of a premature infant with intrauterine herpes simplex encephalitis and hyperleukocytosis (WBC: 116,700/mm 3 ), a double volume exchange transfusion was performed on concerns of high blood viscosity contributing to the risk of neurological injury [5]. References 1. Jain R, Bansal D, Marwaha RK. Hyperleukocytosis: Emergency management. Indian J Pediatr. 2013;80:144–8. 2. Grund FM, Armitage JO, Burns P. Hydroxyurea in the prevention of the effects of leukostasis in acute leukemia. Arch Intern Med. 1977;137:1246–7. 3. Porcu P, Farag S, Marcucci G, Cataland SR, Kennedy MS, Bissell M. Leukocytoreduction for acute leukemia. Ther Apher. 2002;6:15– 23. 4. Romano MJ, Weber MD, Weisse ME, Siu BL. Pertussis pneumonia, hypoxemia, hyperleukocytosis, and pulmonary hypertension: Improvement in oxygenation after a double volume exchange transfusion. Pediatrics. 2004;114:e264–6. 5. Underwood MA, Wartell AE, Borghese RA. Hyperleukocytosis in a premature infant with intrauterine herpes simplex encephalitis. J Perinatol. 2012;32:469–72. D. Bansal (*) : R. Jain Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India e-mail: [email protected] Indian J Pediatr DOI 10.1007/s12098-013-1083-y

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CORRESPONDENCE

Hyperleukocytosis: Emergency Management : Authors’ Reply

Deepak Bansal & Richa Jain

Received: 23 April 2013 /Accepted: 8 May 2013# Dr. K C Chaudhuri Foundation 2013

To the Editor:We thank Gupta et al. for their comments. In apatient with acute leukemia, hyperleukocytosis and Hb>7 g/dL, hydration is initiated at 2–4 times of normalmaintenance. Leukoreduction by either leukapheresis orexchange transfusion is considered if the patient has symp-toms related to leukostasis. If an exchange transfusion isplanned, recommended volume varies from 70 to150 mL/kg, as mentioned in the article [1]. Exchange trans-fusion can be performed with whole blood or with a mix ofpacked red blood cells and plasma (in a ratio of 2–3:1). Onemay prefer a lower concentration of packed red cells (say2:1, instead of 3:1) in a child with a higher Hb, compared toa very anemic child. The decision may be individualized.

It has been rightly pointed that hydroxyurea (HDU) has beenused as a cytoreductive agent, typically in chronic myeloidleukemia (CML) and acute myeloid leukemia (AML). Its useappears to be less popular in pediatric as compared to the adulthematology services. HDU would not need to be considered ina patient with acute lymphoblastic leukemia, as rapidcytoreduction can successfully be achieved with steroidmonotherapy in the large majority. It has been reported thatHDU 50–100mg/kg per day, given orally in 3–4 divided doses,reduces the WBC count by 50 % to 80 % within 24–48 hwithout causing tumor lysis pneumopathy or worsening thedisseminated intravascular coagulation [2]. According to Porcuet al. it should be started immediately in all patients withhyperleukocytic AML and continued until more definitive che-motherapy is initiated [3]. HDU has a definitive role in CML.

Leukemoid reaction severe enough to cause hyper-leukocytosis is very rarely encountered and reported inliterature. Exchange transfusion has been recommended inthe setting of pertussis pneumonia with hyperleukocytosisand pulmonary hypertension [4]. In a case report of a pre-mature infant with intrauterine herpes simplex encephalitisand hyperleukocytosis (WBC: 116,700/mm3), a double vol-ume exchange transfusion was performed on concerns ofhigh blood viscosity contributing to the risk of neurologicalinjury [5].

References

1. Jain R, Bansal D, Marwaha RK. Hyperleukocytosis: Emergencymanagement. Indian J Pediatr. 2013;80:144–8.

2. Grund FM, Armitage JO, Burns P. Hydroxyurea in the prevention ofthe effects of leukostasis in acute leukemia. Arch Intern Med.1977;137:1246–7.

3. Porcu P, Farag S, Marcucci G, Cataland SR, Kennedy MS, BissellM. Leukocytoreduction for acute leukemia. Ther Apher. 2002;6:15–23.

4. Romano MJ, Weber MD, Weisse ME, Siu BL. Pertussis pneumonia,hypoxemia, hyperleukocytosis, and pulmonary hypertension:Improvement in oxygenation after a double volume exchange trans-fusion. Pediatrics. 2004;114:e264–6.

5. Underwood MA, Wartell AE, Borghese RA. Hyperleukocytosis in apremature infant with intrauterine herpes simplex encephalitis. JPerinatol. 2012;32:469–72.

D. Bansal (*) : R. JainHematology-Oncology Unit, Department of Pediatrics, AdvancedPediatric Center, Post Graduate Institute of Medical Educationand Research, Chandigarh 160012, Indiae-mail: [email protected]

Indian J PediatrDOI 10.1007/s12098-013-1083-y