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Case Reports
. 2025 Apr;65(4):779-784.
doi: 10.1111/trf.18188. Epub 2025 Mar 24.

Exchange transfusion and pre-filter apheresis dilution for hyperviscosity syndrome refractory to conventional therapeutic plasma exchange in a patient with IgA multiple myeloma

Anthony Valin-Thorburn  1 , Sara-Maude Desforges  1 , Daniel Corsilli  1   2 , Jean-Gilles Guimond  1   2 , Jean-Philippe Adam  3   4 , Antonio Maietta  5   6 , Bertrand Routy  1   4   7 , Anne-Sophie Lemay  1   7
Affiliations
Case Reports

Exchange transfusion and pre-filter apheresis dilution for hyperviscosity syndrome refractory to conventional therapeutic plasma exchange in a patient with IgA multiple myeloma

Anthony Valin-Thorburn et al. Transfusion. 2025 Apr.

Abstract

Background: Significant serum paraprotein elevation leading to hyperviscosity syndrome (HVS) is a rare but serious medical complication that has been well documented in patients with hematological malignancies, including multiple myeloma and Waldenström's macroglobulinemia. This condition can result in severe neurological, renal, and cardiac complications. Standard management of symptomatic HVS includes therapeutic apheresis and the prompt initiation of chemotherapy. Although usually successful, apheresis failure due to extreme hyperviscosity has been documented.

Case report: A 73-year-old Caucasian male with neurological symptoms of HVS secondary to IgA monoclonal gammopathy was transferred to our institution for urgent therapeutic plasma exchange (TPE) and HVS management. Due to severe hyperviscosity, it was impossible to obtain blood analysis, and several attempts at standard TPE failed due to clogging in the apheresis tubing. In this life-threatening situation, manual blood exchanges were successfully performed, followed by pre-filter apheresis dilution. This unconventional approach proved to be effective, allowing subsequent laboratory analysis and the continuation of conventional TPE procedures. The patient remained hemodynamically stable throughout the procedure and was subsequently started on definitive chemotherapy treatment.

Conclusion: This case highlights the importance of prompt recognition of HVS in patients presenting with hematological malignancies. The use of manual exchange transfusion, in conjunction with pre-filter dilution, enabled the successful management of a patient with severe HVS in whom conventional TPE was not possible, illustrating an effective alternative approach in urgent hematological care. It also emphasizes the importance of initiating systemic treatment rapidly for the underlying hematological condition to ensure sustained improvement and prevent recurrence of HVS.

Keywords: TPE; plasma exchange; plasmapheresis; refractory hyperviscosity syndrome.

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Conflict of interest statement

All authors declare they have no conflict of interest related to the following case report submission.

Figures

FIGURE 1
FIGURE 1
A saline infusion at a flow rate of 500 mL/h was added for dilution as a “Y” derivative infusion at the junction of the catheter and the tubing carrying the patient's blood, using a 3‐way stopcock valve, upstream from the apheresis machine entry for dilution. [Color figure can be viewed at wileyonlinelibrary.com]
FIGURE 2
FIGURE 2
Diffuse medullar infiltration by a plasmocytic neoplasia with partial plasmablastic differentiation (A) HE coloration, low‐power field (B) HE coloration, high‐power field (C) CD138 coloration. [Color figure can be viewed at wileyonlinelibrary.com]
FIGURE 3
FIGURE 3
Timeline of interventions and laboratory results. [Color figure can be viewed at wileyonlinelibrary.com]
See this image and copyright information in PMC

References

    1. Accorsi P, Passeri C, Onofrillo D, Iacone A. Hyperviscosity syndrome in hematological diseases and therapeutic apheresis. Int J Artif Organs. 2005;28(10):1032–1038. - PubMed
    1. Adams BD, Baker R, Lopez JA, Spencer S. Myeloproliferative disorders and the hyperviscosity syndrome. Emerg Med Clin North Am. 2009;27(3):459–476. - PubMed
    1. Mehta J, Singhal S. Hyperviscosity syndrome in plasma cell dyscrasias. Semin Thromb Hemost. 2003;29(5):467–471. - PubMed
    1. Connelly‐Smith L, Alquist CR, Aqui NA, Hofmann JC, Klingel R, Onwuemene OA, et al. Guidelines on the use of therapeutic apheresis in clinical practice ‐ evidence‐based approach from the writing Committee of the American Society for apheresis: the ninth special issue. J Clin Apher. 2023;38(2):277–278. - PubMed
    1. Debureaux PE, Harel S, Parquet N, Lemiale V, Siguret V, Goubeau L, et al. Prognosis of hyperviscosity syndrome in newly diagnosed multiple myeloma in modern‐era therapy: a real‐life study. Front Immunol. 2022;13:1069360. - PMC - PubMed

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