Hyperviscosity syndrome (HVS) refers to the clinical manifestations of increased serum viscosity that result from elevated levels of paraproteins or other blood products. HVS is associated commonly with plasma cell dyscrasias. HVS classically presents with mucosal bleeding and visual and neurological abnormalities. Treatment for HVS is plasmapharesis, which in safety-net settings may not be available, and may result in poorer outcomes compared to larger cancer centers. However, measures can be taken to temporize while arranging treatment.

A 58-year-old male with IgA multiple myeloma presented to the hospital with confusion and gait instability. Initial blood samples were viscous and the results were deemed unreliable. A CT head only revealed bony lesions, consistent with multiple myeloma. His physical exam was concerning for spinal involvement with lower extremity weakness, hyperreflexia, decreased rectal tone, and urinary retention. Neurosurgery recommended additional spinal imaging, however, the workup was unrevealing. Hematology/oncology was consulted with concerns for HVS. Temporizing measures were performed with IV fluids, rapid acting chemotherapy, and transfusions while awaiting plasmapheresis. He had waxing and waning mentation for the next few days, and slowly improved over his hospital course.

HVS is an oncologic emergency and requires prompt recognition and treatment. In many safety net hospitals plasmapheresis may take time to arrange in which case some patients with severe HVS may succumb to further complications. Clinical sequelae of HVS include heart failure, acute renal failure, pulmonary edema with multi-organ system failure, and death. In severe cases there has been shown to be benefit to therapeutic phlebotomy, IV fluid administration, and rapid acting chemotherapy if plasmapheresis cannot be arranged emergently, which is common in safety-net hospitals. There continues to be a need for investigation of outcomes in low resource hospitals versus large cancer centers where specialized therapies are readily available in order to bridge the gap in disparities.