Abstract:
A 48-year-old male diagnosed with Acute promyelocytic leukemia (APL)
started on all-trans retinoic acid and arsenic trioxide, developed
typical symptoms of differentiation syndrome, and improved dramatically
on steroids. Hence, any APL patient started on chemotherapy, needs to be
monitored closely for developing differentiation syndrome and to start
steroid upon suspicion.
Case presentation:
A 48-year-old male diagnosed with APL started on all trans-retinoic
acid (ATRA) and arsenic trioxide(ATO) as per protocol (1), on day 2 he
started to have fever, dyspnea, hemoptysis. Chest X-ray (CXR) showed
bilateral infiltration (Figure A) and patient was started on
dexamethasone, based on suspicion of differentiation syndrome. Patient
improved significantly within 24 hrs, and follow-up CXR showed
resolution of infiltrates (Figure B). Diagnosis of differentiation
syndrome requires 3 or more of clinical features: fever> 38
c , weight gain >5 kg , hypotension, dyspnea, radiographic
opacities, pleural or pericardial effusion & Acute renal failure (2).
Treatment is dexamethasone 10 mg twice daily initially, and then to
adjust the steroid dose based on patient clinical status.
Differentiation syndrome is a fatal complication therefore there should
be high index of suspicion in APL patients who deteriorates after
starting chemotherapy and to start treatment empirically.