대한흉부영상의학회 Korean Society of Thoracic Radiology

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Weekly Chest CasesArchive of Old Cases

Case No : 348 Date 2004-06-26

  • Courtesy of Yon Mi Sung, M.D., Tae Sung Kim, M.D. / Samsung Medical Cneter, Sungkyunkwan University, Seoul, Korea
  • Age/Sex 51 / F
  • Chief ComplaintDyspnea during induction chemotherapy for AML (M3)
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Diagnosis With Brief Discussion

Diagnosis
ATRA (All trans-retinoic acid) syndrome
Radiologic Findings
Chest PA shows diffuse gound-glass opacities in both lungs and nodular consolidation in left lower lung zone. Bilateral pleural effusion is also seen.

HRCT with lung settings shows diffuse ground-glass attenuation, airspace consolidation and mild interlobular septal thickening in both lungs. Small amount of bilateral pleural effusion is accompanied with that.
Brief Review
ATRA is used as an accepted therapy for acute promyelocytic leukemia(M3). ATRA can differentiate acute promyelocytic leukemia blasts into mature granulocytes. ATRA is usually well tolerated, but major side effects can be observed, the ATRA syndrome being the most important of them.

ATRA syndrome refers to a constellation of findings, includig unexplained fever, fluid retention, multiple sites of hemorrhage, organ failure, and thrombotic events (1). 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 (2). In addition, chest radiography may show nodules and consolidation (2). Some patients with ATRA syndrome have to receive mechanical ventilation because of severe hypoxemia (1, 3). 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, 4).
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. 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

3. 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

4. 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, Iatrogenic lung disease, Drug complication,

No. of Applicants : 31

▶ Correct Answer : 14/31,  45.2%
  • - Annecy Hospital, France Gilles Genin
  • - Asan Medical Center, Korea Eun Jin Chae
  • - Centre d'imagerie Jacques Callot, Nancy, France Lionel Cannard
  • - Dong-A University Hospital, Korea Ki-Nam Lee
  • - Escola Paulista de Medicina, Brazil Jose LM de Almeida Prado
  • - Ev. Krkhs. Hubertus, Berlin, Germany Michael Weber
  • - Ewha Woman's University Hospital, Korea Yoo Kyoung Kim
  • - Mallinckrodt Institute of Radiology, USA Jin Mo Goo
  • - National Taiwan University Hospital, Taiwan Tan Che Kim
  • - National Taiwan University Hospital, Taiwan Sheng-Hsiang Lin
  • - Samsung Medical Center, Korea Semin Chong
  • - Sharma Clinic, Jaipur, India Dinesh Sharma
  • - Social Security Hospital, Ankara, Turkey Meric Tuzun
  • - UNIFESP-EPM and Fleury Med. Ctr, Sao Paulo, Brazil Gustavo Meirelles
▶ Semi-Correct Answer : 12/31,  38.7%
  • - Air force education & training command Hospital, Korea Hyukwon Chang
  • - CHU Grenoble, France Mathieu Rodiere
  • - CHU Nancy-Brabois, France Denis Regent
  • - CIM Saint Dizier, France JC Leclerc
  • - Eulji hospital, Korea Jeong Joo Woo
  • - GeojeBaek Hospital, Gyungnam, Korea James Lim
  • - Hangang SacredHeart Hospital, Korea Eil Seong Lee
  • - Hanyang University Hospital, Seoul, Korea Yo Won Choi
  • - Homs National Hospital, Homs, Syria Rami Abou Zalaf
  • - MH(CTC), Pune, India Vivek Sharma
  • - Shin Kong Memorial Hsopital, Taipei, Taiwan Diana Yeh
  • - UNIFESP-EPM and Ctr of Diag. Brazil, Sao Paulo, Brazil BrazilIsabela Silva
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