Program: Section on Critical Care Program (H3001, H4406)
P0448 - Acute Onset Bilateral Blurry Vision as Sole Presenting Complaint for Underlying Acute Lymphoblastic Leukemia
Introduction: When we think about the initial symptoms of malignancy the symptoms that typically come to mind are those such as fatigue, unintentional weight loss, lymphadenopathy, or bone pain; though sometimes oncologic emergencies may not present in textbook ways and so it is important to always keep a broad differential when initially evaluating patients and gathering data.
Case Description: A 12 year-old female with no medical history presented to the emergency department with 1 day of bilateral blurry vision. She was in her usual state of health until that morning when she awoke with blurry vision that persisted throughout the day. ROS was negative for trauma, fevers, fatigue, changes in appetite or weight, headaches, history of eye problems, nausea, changes in bowel or urinary habits, numbness, weakness, easy bruising, or rashes. Vitals were T 36.9C, BP 108/62, HR 118, RR 20, Sp2 98% on RA. Ophthalmologic evaluation revealed severe bilateral papilledema, macular edema, and tortuous blood vessels with flame hemorrhages; the rest of the physical exam was normal. MRI/MRV demonstrated mild tortuosity of the optic nerve sheath complexes, moderate length right transverse sinus stenosis and focal stenosis of the left transverse sinus, and mild upper cervical lymphadenopathy. Given clinical and radiographic concern for idiopathic intracranial hypertension, the tentative plan was to perform a lumbar puncture after basic labs had resulted. The BMP resulted first and was notable for K of 5.5. PT, INR, and PTT were 14.7 seconds, 1.3, and 32.4 seconds, respectively. At this point, roughly 2 hours after initial presentation to the emergency department, the patient was reevaluated and had developed petechiae on her ankles bilaterally and on the anterior trunk area. The CBC eventually resulted with WBC 494,700/uL, Hg 5.8 g/dL, Plts 13,000/uL, and a differential with 95% blasts. The hematology/oncology team was consulted. Tumor lysis labs were added on and were notable for uric acid of 12.2 and LDH >4200. Repeat K was 6.3. The patient was started on hyperhydration and allopurinol and was transferred to the PICU for further management of hyperleukocytosis and hyperkalemia. She eventually required leukapheresis. Bone marrow biopsy confirmed diagnosis of early T-cell precursor acute lymphoblastic leukemia.
Discussion: This case demonstrates that though we are taught about many of the classic clinical symptoms suggestive of malignancy, it is important to always keep a broad differential when evaluating patients, as some patients may have uncommon clinical presentations of life-threatening conditions that require prompt diagnosis and life-saving treatment.
Conclusion: Malignancy can have an acute presentation with uncommon symptomatology and should always be considered when evaluating patients.