대한흉부영상의학회 Korean Society of Thoracic Radiology

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Weekly Chest CasesArchive of Old Cases

Case No : 685 Date 2010-12-14

  • Courtesy of Sang Hyun Baek / Soonchunhyang university hospital
  • Age/Sex 60 / M
  • Chief ComplaintCough, Acute promyelocytic leukemia (M3)
  • Figure 1
  • Figure 2
  • Figure 3

Diagnosis With Brief Discussion

Diagnosis
All trans retinoic acid syndrome
Radiologic Findings
Chest PA shows engorged pulmonary artery in both lungs and bilateral pleural effusion is also seen.
HRCT shows airspace consolidation,ground-glass attenuation, and interlobular septal thickening in both lungs. Bilateral pleural effusion is accompanied. Pulmonary artery is engorged in both lungs.
Brief Review
ATRA is an effective therapy for acute promyelocytic leukemia(M3). ATRA can differentiate acute promyelocytic leukemia blasts into mature granulocytes reduce the risk of disseminated intravascular coagulation with few cytotoxic effects. ATRA is usually well tolerated, but major side effects can be observed, the ATRA syndrome being the most important of them.

ATRA syndrome occurs in up to 25% of the patients reated with ATRA. ATRA syndrome characterized by dypnea, unexplained fever, weight gain, fluid retention, multiple sites of hemorrhage, organ failure, and thrombotic events (1,2). Chest radiographic features of the ATRA syndrome include increased cardiothoracic ratio, increased vascular pedicle width, ground-glass opacity, peribronchial cuffing, septal lines, and pleural effusion (3). Some patients with ATRA syndrome have to receive mechanical ventilation because of severe hypoxemia (1, 4). However, once a diagnosis of ATRA syndrome has been made, a prompt recovery can be achieved by withdrawing ATRA and treating the patient with prednisolone (1, 5).
References
1. Frankel SR, Eardley A, Lauwers G, Weiss M, Warrel RP. The "retinoic acid syndrome" in acute promyelocytic leukemia. Ann Intern Med 1992;117:292-296
2. De Botton S, Dombret H, Sanz M et al. Incidence, clinical features, and outcome of all trans-retinoic acid syndrome in 413 cases of newly diagnosed acute promyelocytic leukemia. Blood 1998;92:2712-2718
3. Jung JI, Choi JE, Hahn ST, Min CK, Kim CC, Park SH. Radiologic features of all-trans-retinoic acid syndrome. AJR 2002;178:475-480
4. De Botton S, Dombret H, Sanz M et al. Incidence, clinical features, and outcome of all trans-retinoic acid syndrome in 413 cases of newly diagnosed acute promyelocytic leukemia. Blood 1998;92:2712-2718
5. Tallman MS, Andersen JW, Schiffer CA, et al. Clinical description of 44 patients with acute promyelocytic leukemia who developed the retinoic acid syndrome. Blood 2000;95:90-95
Keywords
Lung, Non-infectious inflammation, Drug complication,

No. of Applicants : 89

▶ Correct Answer : 38/89,  42.7%
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - All India Institute of medical sciences , India Justin Moses
  • - Onomichi municipal hospital , Japan Junya Itakura
  • - Osaka University , Japan Osamu Honda
  • - Okayama University , Japan Akihiro Tada
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - seoul national university hospital , Korea (South) Ijin Joo
  • - Mie-chuo hosp. , Japan Hitoshi KODERA
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - Assam medical college , India Aparimita g
  • - Okayama university , Japan Takeharu Yamamoto
  • - kobe city general hospital , Japan rintaro hashimoto
  • - Hangang sacred heart hospital , Korea (South) You Mie Han
  • - McGill , Canada Marcus Povitz
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - Catholic medical center , Korea (South) hyuna kim
  • - McGill , Canada ilan azuelos
  • - Kobe City Medical Center General Hospital , Japan Hitomi Nagano
  • - Sunchun university hospital, Bucheon , Korea (South) So Young Bae
  • - PingTung Christian Hospital ,China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - SNUH , Korea (South) Eun LEE
  • - Inha University Hospital , Korea (South) Ju Won Lee
  • - KHOO TECK PUAT HOSPITAL , Singapore SUMER SHIKHARE
  • - Univ. of Miami/Jackson Memorial , United States mantosh rattan
  • - Kobe City Medical Center General Hospital , Japan Junko Ochi
  • - Toyama University Hospital, Laboratory of Pathology , Japan TOMONORI TANAKA
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - Hotel-Dieu Montreal , Canada nicolas gautier
  • - Asan Medial center , Korea (South) Chaehun Lim
  • - National Taiwan University Hospital , Taiwan Li-Ta Keng
  • - Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - Yonsei University College of Medicine, Severance Hospital , Korea (South) Hyung Jin Rhee
  • - Vital Imaging Centre, Mumbai,India , India Ganesh Agrawal
  • - NASA SCANS , India RAKESH BHATIA
  • - Beaulieu clinic Geneva , Switzerland gilles GENIN
▶ Correct Answer as Differential Diagnosis : 1/89,  1.1%
  • - NTUH , Taiwan Kuei-pin Chung
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