Hyperviscosity syndrome (HVS) is a condition caused by an increase in the viscosity of blood, making it thicker and less able to flow easily. This can lead to organ dysfunction. HVS occurs when there is an abnormal increase in certain blood components like red blood cells, white blood cells, platelets or proteins. Common causes include polycythemia, leukemia, myeloma and other blood disorders. Patients may experience symptoms like bleeding, visual changes, neurological issues, respiratory problems and renal impairment. Diagnosis involves blood tests, imaging and assessing the underlying condition causing the increased viscosity. Treatment focuses on treating the underlying cause, stabilizing the patient, and procedures like plasmapheresis, hydration and phlebot

1. Hyperviscosity Syndrome
By
Mohamed AbdElmotaal Safa
Ass. Lecturer of Internal Medicine
Faculty of Medicine
Tanta University

4. PPhhyyssiioollooggiiccaall bbaacckkggrroouunndd

5. Viscosity is a property of
liquid that exhibits its resistance
to the flow of one layer over
. another
Blood as a circulating tissue
is composed of fluid plasma
, and cells (red blood cells
(.white blood cells, platelets
For blood to be viscid affection of its component should
.Occure

6. PLASMA
(to 90% 85(
CELLS
(to 15% 10(
RBCs .Plat WBCs
Polycyathemia
Thrombocytosis
Leukemia
Monoclonal
Polyclonal
HHVV ooff BBlloooodd
MMMM
WWMM
MMGGUUSS
11rryy AAmmyyllooiiddoossiiss
HHeeaavvyy cchhaaiinn
ddiisseeaassee
IInnffeeccttiioonnss
TTuummoorrss
LLiivveerr ffaaiilluurree
CCoollllaaggeenn ddiisseeaassee
SSaarrccooiiddoossiiss

7. PPaatthhoopphhyyssiioollooggyy
HV of blood leads to
vascular stasis and
resultant hypoperfusion
then lead to the clinical
symptoms HVS.

8. Epidemiology
AGE
SEX
MORTALITY
More in old age
More in males
Related to
cause &complications

9. Epidemiology
Data are non conclusive
due to lake of
informations
AGE
SEX
MORTALITY
More in old age
More in males
Related to
cause &complications

10. CCLLIINNIICCAALL PPIICCTTUURREE 33××33
Mucosal bleeding
Visual changes
Neurological symptoms
Cardiopulmonary
symptoms
Renal symptoms
&Dermatological
. Constitutional sym

11. Mucosal bleeding
• SSppoonnttaanneeoouuss gguumm bblleeeeddiinngg
• EEppiissttaaxxiiss
• RReeccttaall bblleeeeddiinngg
• MMeennoorrrrhhaaggiiaa
• PPeerrssiisstteenntt bblleeeeddiinngg aafftteerr mmiinnoorr
procedures

13. VViissuuaall cchhaannggeess
rraannggee ffrroomm bblluurrrreedd vviissiioonn ttoo vviissiioonn lloossss..
Change in visual acuity: (BlurringDiplopiaVisual
loss)
Characteristic “link-sausage effect” on funduscopy
Alternating bulges and constrictions within the
retinal
veins
Retinal hemorrhage, detachment
Exudate, microaneurysm formation
Papilledema

15. NNeeuurroollooggiiccaall ssyymmppttoommss
FFrreeqquueenntt&&VVaarriiaabbllee
• VVeerrttiiggoo
• HHeeaarriinngg lloossss
• PPaarreesstthheessiiaass
• AAttaaxxiiaa
• HHeeaaddaacchheess
• SSeeiizzuurreess
• SSoommnnoolleennccee pprrooggrreessssiinngg ttoo ssttuuppoorr aanndd
ccoommaa

17. CCaarrddiiooppuullmmoonnaarryy
ssyymmppttoommss
CCoonnssttiittuuttiioonnaall
ssyymmppttoommss
Dyspne
Dysrhythmias
Hypoxia
Heart failure
Fatigue
Lethergy
Anorexia

18. DDeerrmmaattoollooggiiccaall
RReennaall ssyymmppttoommss
RRaayynnaauudd pphheennoommeennoonnoo
LLiivveeddoo rreettiiccuullaarriiss
PPaallppaabbllee ppuurrppuurraa
EErruuppttiivvee ssppiiddeerr nneevvuuss––lliikkee
DDiiggiittaall iinnffaarrccttss
PPeerriipphheerraall ggaannggrreennee
Nephritic or
nephrotic syndrome
hematuria
Sterile pyuria

19. PPeeaarrll ttoo bbee
hhiigghhlliigghhtteedd
To early diagnose a patient
with HVS you should have
high index of suspicion for
it
in any patient with
unexplained
MMuuccoossaall bblleeeeddiinngg
((NNoossee&&gguumm))
NNeeuurroollooggiiccaall CCOO
…………HHeeaaddaacchhee
BBlluurrrriinngg ff vviissiioonn
DDyyssppnneeaa
EEssppeecciiaallllyy tthhoossee wwiitthh uunnddeerrllyyiinngg bblloooodd ddiisseeaassee

20. PPhhyyssiiccaall EExxaammeennaattiioonn
Related to the cause : spleanomegaly &flushed
face in PRV
:Related to organ affected
Bruises, epistaxis, or gum bleeding may be noted
Ophthalmic examination :decreased visual acuity,dilated retinal
veins, "sausage-linked"of the retinal veins, or retinal Hge
, Neurologic examination may reveal various abnormalities
including diminished mental status, confusion, ataxia, or
nystagmus
Cardiopulmonary examination may reveal signs of CHF with
(volume overload (rales, LLO,CNV, and hypoxia

21. DIAGNOSTIC WORKUP

22. HHiissttoorryy && CClliinniiccaall
eexxaammeennaattiioonn
Lab. Investigations
Imaging

23. HHiissttoorryy && CClliinniiccaall
eexxaammeennaattiioonn
Put in mind any Pt presented with
especially if unexplained and the 3×3
Pt is suspected to have underlying
hematological disease

24. . Put in mind lab •
Comment on the •
P t samples if it •
is
difficult in •
manipulations •
and
separation •

25. Lab. clues
CBC with blood film
Globulin gap
Measurement of serum
viscosity
Metabolic panel and
Electrolyte
Urine analysis
Coagulation profile
Important markers
SPEP and SPIF

26. CBC with blood film
Erythrocytosis
Leukemia
Thrombocytosis
N N anemia with
rouleaux formation

27. Globulin gap
Consider measuring total protein
,TP) and albumin)
; as in the paraproteinemias
a globulin gap
TP – albumin = 4 or greater) may )
exist

28. Measurement of serum viscosity
Ostwald viscosimeter
Normal range for the
serum viscosity relative
.to water is 1.4–1.8
Minimal viscosity at
which symptoms
develop is 4.0 centipoise
(.cp )

29. :Metabolic panel and Electrolyte
Renal dysfunction is commonly
noted in HVS
Hypercalcemia and pseudohyponatremia
in MM

30. : Urine analysis
Proteinuria
Hematuria
Sterile pyuria
BJP
Protein Electrophoresis

31. Coagulation profile
For any coagulopathy
workup
…PT,PTT,BT)

32. Important markers
LDH, B2 Microglobulins, serum
vit B 12
Uric acid and ALP.

33. SPEP and SPIF

34. Tailor additional workup •
according
• to patient presentation

35. Imaging
Bone survey
Us abdomen and Pelvis
CT &MRI brain
CXR
ECHO cardiography

36. TREATEMENT

37. Pre-hospital Stabilization Therapy
A,B,C Care with keeping
IV fluid axis(Rehydrate with
0.9% NS IV fluid.)
Avoid blood transfusion ?

38. Emergency Departement Treatment
plasmapheresis
Hydration
Early apheresis
and phlebotomy
Standard therapies
For CHF, bleeding…
platletpheresis
leukapheresis
Erythrocytosis

39. Be Wise enough☺
Be careful in p RBCs transfusion even
when needed (v.slow)
Diuretic may worsen the condition
TLS can occure easily with leukapheresis
IDA can occure from repeated venesiction
and lead to microcytosis with more HV
Phlebotomy with hydration (in non
anemic Pt)may be clue Till Apheresis is
available

40. Note that the definitive
treatment of HVS is
treatment of the
underlying disorder
eg, chemotherapy). If)
the underlying disease
process is left untreated
. the HV will recur,

41. Prognosis
:It depends on
Severity of the complications,
The underlying cause
Response of the appropriate definitive
treatment.

42. NNooww…….. MMeennttaall bbrreeaakk !!
......إإننسسوواا
......إإننسسوواا
......إإننسسوواا

44. HVS is a clinical entity that can be fatal but can also
be
easily treated if early diagnosed
For health care supervisors to diagnose HVS they
must
Have high index of suspicion towards Unexplained
mucosal bleeding dyspnea and coma
Blood film is very important and may be clue for
many
case
Keep in mind lab. Comments on your patient
samples
.If it is repeatedly condense and block lab. Machines
Be wise enough in judging patients with HVS even
in
Treating current problem you may worsen the matter

45. SSuurree yyoouu aarree
ttiirreedd......
EEnnoouugghh
......!!PPlleeeeeeeeeezz