title: [Acute promyelocytic leukemia accompanied by retinoic acid syndrome with complications of acute myocardial infarction and cerebral infarction during treatment with all-trans retinoic acid].
abstract: A 71-year-old man visited our hospital complaining of fever and a bleeding tendency. The peripheral blood WBC count was 10,400/microliter with 90% promyelocytes. The bone marrow was hypercellular with 88% promyelocytes. Disseminated intravascular coagulation was recognized. The patient was diagnosed as having acute promyelocytic leukemia and was treated with daily oral administration of all-trans retionic acid (ATRA) (45 mg/m2/day) and cytarabine (160 mg/day, intravenous drip infusion for the initial five days). The ATRA treatment induced leukemic cells to undergo mature myeloid differentiation. On day 24 after the start of treatment, the WBC count rapidly increased and acute myocardial infarction appeared, with consciousness disturbance and bilateral Babinski reflex appearing three hours later. Magnetic resonance imaging showed a fresh lacunar infarction of the right lenticular nucleus, and serum levels of IL-6 and PAI-1 were found to be elevated at the onset of infarction. Since there was a possibility that the retinoic acid syndrome (RAS) might have helped bring about the infarctions, we stopped the ATRA treatment and started administration of methyl-prednisolone (500 mg/body/day for 3 days) and gabexate mesilate. The WBC count decreased immediately and the consciousness disturbance improved. In this case, ATRA treatment might have initiated the RAS and resulted in some endothelial damage, thus causing the infarctions.
authors.affiliation: Division of Hematology, Department of Medicine, Jichi Medical School.
authors.forename: Takuji
authors.initials: T
authors.lastname: Miyoshi
authors.forename: Tetsuya
authors.initials: T
authors.lastname: Otsuki
authors.forename: Ken
authors.initials: K
authors.lastname: Omine
authors.forename: Keita
authors.initials: K
authors.lastname: Kirito
authors.forename: Tadashi
authors.initials: T
authors.lastname: Nagai
authors.forename: Tohru
authors.initials: T
authors.lastname: Izumi
authors.forename: Norio
authors.initials: N
authors.lastname: Komatsu
authors.forename: Seiji
authors.initials: S
authors.lastname: Madoiwa
authors.forename: Jun
authors.initials: J
authors.lastname: Mimuro
authors.forename: Yoichi
authors.initials: Y
authors.lastname: Sakata
authors.forename: Keiya
authors.initials: K
authors.lastname: Ozawa
mesh_terms: D000368:Aged; D000970:Antineoplastic Agents / Q000009:adverse effects*; D002544:Cerebral Infarction / Q000209:etiology*; D006801:Humans; D015473:Leukemia, Promyelocytic, Acute / Q000150:complications* / Q000188:drug therapy; D008297:Male; D008775:Methylprednisolone / Q000008:administration & dosage; D009203:Myocardial Infarction / Q000209:etiology*; D020551:Pulse Therapy, Drug; D014212:Tretinoin / Q000009:adverse effects*
chemical_list: D000970:Antineoplastic Agents; D014212:Tretinoin; D008775:Methylprednisolone