tretinoin and Pancytopenia

A 19-year-old man was referred to our hospital with pancytopenia and disseminated intravascular coagulation (DIC). Bone marrow aspiration revealed 93.6% of atypical promyelocytes and marked hemophagocytosis by macrophages. The diagnosis of acute promyelocytic leukemia (APL) associated with hemophagocytic syndrome (HPS) was made. As there was no evidence of infection, collagen diseases, or abuse of medicine, his HPS was classified as malignancy-associated HPS (MAHS). The DIC improved after administration of idarubicin and all-trans-retinoic acid (ATRA). On the 11th day, however, DIC and elevation of serum LDH recurred with the appearance of hepatosplenomegaly. Although APL cells had decreased in the bone marrow, hemophagocytes persisted. After administration of dexamethasone and etoposide, DIC and HPS improved, and complete remission of APL was obtained. ATRA was implicated in the aggravation of APL-induced MAHS in the present case.

Topics: Adult; Antineoplastic Combined Chemotherapy Protocols; Dexamethasone; Disseminated Intravascular Coagulation; Etoposide; Humans; Idarubicin; Leukemia, Promyelocytic, Acute; Lymphohistiocytosis, Hemophagocytic; Male; Pancytopenia; Treatment Outcome; Tretinoin

BACKGROUND Acute promyelocytic leukemia (APL) is a rare subtype of acute myeloid leukemia (AML) and is characterized by a genetic translocation affecting the retinoic acid receptor-alpha gene, leading to blockage in the differentiation of granulocytic cells. The accumulation of promyelocytes in bone marrow leads to cytopenias and life-threatening coagulopathies. Definitive diagnosis is made with bone marrow biopsy. Differentiation of APL from other leukemias is important to appropriately treat with all-trans retinoic acid (ATRA) and arsenic trioxide. Patients with HIV are at a higher risk to develop AML. This article identifies how multiple comorbidities and social factors can contribute to difficulties in diagnosing AML. CASE REPORT We present a 67-year-old man with a past medical history of hypertension and substance use disorder who presented with progressive exertional dyspnea and was found to have HIV, chronic hepatitis C, and APL with pancytopenia. His bone marrow biopsy confirmed AML. This was a case of co-existing HIV and aleukemic leukemia. CONCLUSIONS APL can present with pancytopenia, weakness, failure to thrive, or bleeding complications, which can be similar to presentations of those diagnosed with HIV. Diagnosis of APL can be differentiated between hypergranular and hypogranular; our patient demonstrated APL with only 52% blasts, which can make for a challenging diagnosis. Given increased mortality of APL, immediate ATRA therapy is warranted. Aleukemic leukemia is a rare presentation typically accompanied by skin manifestations. Our case highlights the importance of having high clinical suspicion for malignancy in patients with comorbidities that can interfere with the classic presentation of leukemia.

Topics: Aged; Alcoholism; Hepatitis C; HIV Infections; Humans; Leukemia, Promyelocytic, Acute; Male; Pancytopenia; Tretinoin

Topics: Abdomen; Acute Kidney Injury; Aged, 80 and over; Anaplasma phagocytophilum; Antineoplastic Agents; Bone Marrow Examination; Diagnosis, Differential; Ehrlichiosis; Fibrin Fibrinogen Degradation Products; Humans; L-Lactate Dehydrogenase; Leukemia, Promyelocytic, Acute; Male; Pancytopenia; Thorax; Tomography, X-Ray Computed; Tretinoin

Staphylococcus aureus as a pathogen in human gestational membranes, a rather rare phenomenon, has recently been the focus of several researches. S. aureus forms biofilms on these membranes and potentially causes chorioamnionitis in pregnant women. We report a case of persistent methicillin-resistant S. aureus (MRSA) bacteremia owing to placental infection, causing chorioamnionitis and preterm birth. A 29-year-old Japanese woman at the 27th gestational week was diagnosed with acute promyelocytic leukemia and underwent all-trans retinoic acid therapy. Soon after hospitalization, the patient presented with persistent MRSA bacteremia of unknown origin. Despite various antimicrobial therapies, she experienced 12 MRSA bacteremia episodes over 6 weeks. However, after child birth, MRSA bacteremia disappeared without any complications. A pathologic examination of her placenta revealed placenta abscess, resulting in a diagnosis of MRSA-associated chorioamnionitis. Molecular analysis proved that a single MRSA strain (SCCmec Type IVa), which tested negative for Panton-Valentine leukocidin and toxic shock syndrome toxin-1, caused the obstinate infection. We should be aware that persistent MRSA bacteremia in pregnant women can originate from placental abscess.

Topics: Abdominal Abscess; Adult; Bacteremia; Bacterial Toxins; Chorioamnionitis; Exotoxins; Female; Humans; Leukemia, Promyelocytic, Acute; Leukocidins; Methicillin-Resistant Staphylococcus aureus; Pancytopenia; Placenta; Pregnancy; Staphylococcal Infections; Tretinoin

Topics: Acute Disease; Adenocarcinoma; Antineoplastic Agents; Capecitabine; Chemoradiotherapy; Colorectal Neoplasms; Female; Humans; Idarubicin; Leukemia, Promyelocytic, Acute; Middle Aged; Neoplasms, Second Primary; Organoplatinum Compounds; Oxaliplatin; Pancytopenia; Primary Myelofibrosis; Remission Induction; Tretinoin

The case of an adult with PML/RARalpha(+) hypergranular acute promyelocytic leukemia (M3) that evolved into a rapidly fatal M3 acute myelocytic leukemia without PML/RARalpha after a complete and molecular remission had been achieved, is presented. Only 7 such cases have been published in the literature. The possible origin of this either leukemic relapse or secondary malignancy is briefly discussed, focusing on the fact that this diagnosis could only be defined by adequate molecular biology studies in the leukemic cells.

Topics: Adult; Humans; Leukemia, Promyelocytic, Acute; Male; Neoplasm Proteins; Oncogene Proteins, Fusion; Pancytopenia; Receptors, Retinoic Acid; Recurrence; Retinoic Acid Receptor alpha; Reverse Transcriptase Polymerase Chain Reaction; Tretinoin

In 26 acute promyelocytic leukaemia (APL) patients treated with all-trans retinoic acid (ATRA), 23% had platelet counts between 459 and 800 x 10(9)/I during treatment. These values, observed between days 28 and 45 of ATRA treatment, were transient and asymptomatic. We report two APL cases with platelet counts > 1000 x 10(9)/I during ATRA therapy who were treated with recombinant interferon alpha. In both cases ATRA doses were not modified, no complications secondary to thrombocytosis were seen, and they subsequently achieved complete remission. It is suggested that IL-6 may play an important role in the pathogenesis of the thrombocytosis induced by ATRA. To our knowledge, this is the first report of thrombocytosis occurring during ATRA treatment.

Topics: Adolescent; Adult; Female; Humans; Leukemia, Promyelocytic, Acute; Male; Pancytopenia; Thrombocytopenia; Thrombocytosis; Tretinoin

Topics: Bone Marrow; Humans; Infarction; Leukemia, Promyelocytic, Acute; Leukocytosis; Male; Middle Aged; Pancytopenia; Tretinoin