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Leucocytosis, hyperviscosity syndrome and acute coronary syndrome: case report A 47-year-old patient [sex not stated] developed leucocytosis during treatment with lipegfilgrastim for prophylactic granulocyte colony stimulating factor (G-CSF) therapy. Additionally, the patient also developed acute coronary syndrome secondary to hyper-viscosity syndrome during treatment with fluorouracil and irinotecan for pancreatic ductal adenocarcinoma [routes and dosages not stated]. The patient, who was diagnosed with pancreatic ductal adenocarcinoma in November 2018, underwent a lymphadenectomy, cholecystectomy and splenectomy. The patient was scheduled to received 12 cycles of adjuvant FOLFIRINOX regimen including folinic acid, fluorouracil, irinotecan and oxaliplatin, over 6 months. The patient received the first and second cycle of FOLFIRINOX, which was modified to include lipegfilgrastim for G-CSF prophylaxis February 2019, to prevent neutropenia. However, the patient developed leucocytosis associated with lipegfilgrastim. Additionally, the leucocytosis interacted with the patient’s concurrent thrombocytosis and led to acute coronary syndrome with thromboembolic occlusions of the distal left anterior descending artery (LAD), ramus interventricularis posterior and the distal ramus diagonalis. The treatment with fluorouracil and irinotecan was thought to contribute in the development of acute coronary syndrome. The presence of coronary heart disease was excluded, however, myocardial infarction was noted. The patient was admitted to hospital and underwent an aspiration of thrombi in the area of LAD, however, it was not successful. The patient started receiving treatment with tirofiban. In April 2019, the patient’s third cycle of adjuvant therapy with FOLFIRINOX was initiated. On 16 July 2019, the patient had completed the 12th cycle of the chemotherapy without any complications. Author comment: [T]he patient received a G‑CSF prophylaxis with lipegfilgrastim. This led to a significant leucocytosis, . . .and other unknown factors led to a hyperviscosity syndrome, which then ultimately caused thromboembolic occlusions of multiple coronary arteries in an actually heart healthy patient. The potential cardiotoxicity and thrombogenicity of 5-FU [fluorouracil] and irinotecan were also included in the differential diagnosis. Holzhauer P. Acute Coronary Syndrome while Receiving Chemotherapy and up-todate Supportive Therapy. [German]. Deutsche Zeitschrift fur Onkologie 51: 139-140, No. 3, Sep 2019. Available from: URL: http://doi.org/10.1055/ 803436281 a-0977-6718 [German; summarised from a translation] - Germany

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Reactions 30 Nov 2019 No. 1781