SHM Converge Scientific Abstract ePoster Gallery-Cytoreduction to Prevent Differentiation Syndrome in High-Risk Acute Promyelocytic Leukemia

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This case describes a 25-year-old woman diagnosed with high-risk acute promyelocytic leukemia (APML), presenting with two weeks of vaginal bleeding, weakness, fever, chills, body aches, and progressive vision loss. On exam she was tachycardic, hypoxic, and pale, with active bleeding. Initial labs showed severe pancytopenia, marked leukocytosis (WBC 74K/µL), low fibrinogen, elevated INR, and peripheral smear findings suggestive of APML, including Auer rods. Diagnosis was confirmed by bone marrow biopsy and FISH.<br /><br />Because high-risk APML carries a substantial early mortality risk, the team emphasized rapid treatment and prevention of differentiation syndrome, a serious complication associated with ATRA-based therapy. She was treated with ATRA-ATO induction, gemtuzumab ozogamicin, hydroxyurea, and cytarabine for cytoreduction given her very high WBC count. Prednisone was started for differentiation syndrome prophylaxis. Supportive care included cryoprecipitate to raise fibrinogen, platelet transfusions, vitamin K, and tumor lysis monitoring. Ophthalmology evaluated her vision loss, which was felt likely due to leukemic retinopathy and improved with treatment of the leukemia.<br /><br />During hospitalization, she developed hypoxia, dyspnea, and volume overload with elevated right atrial pressure, which improved with diuresis. She also had recurrent epistaxis, but no severe differentiation syndrome occurred. Vaginal bleeding resolved, and vision continued to improve before transfer of care closer to home.<br /><br />The report highlights that APML is highly curable with treatment, but the diagnosis and early treatment period are dangerous and require close monitoring, risk stratification, transfusion support, and prompt cytoreduction in high-risk patients.

Asset Subtitle

Justine T. Hung

Meta Tag

Author List Justine T. Hung, Kalyan Nadiminti

Category Clinical Vignettes

Concept Acute Promyelocytic Leukemia

Concept Differentiation Syndrome

Concept Hematologic Emergency

Concept All-Trans Retinoic Acid

Concept Arsenic Trioxide

Distinguished Non-Finalist

Presenter Organization University of Wisconsin

Presenting Author Justine T. Hung

Track Adult

Keywords

acute promyelocytic leukemia

APML

high-risk leukemia

ATRA-ATO therapy

differentiation syndrome

leukocytosis

Auer rods

pancytopenia

leukemic retinopathy

cytoreduction

Acute Promyelocytic Leukemia

Differentiation Syndrome

Hematologic Emergency

All-Trans Retinoic Acid

Arsenic Trioxide