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Weekly Chest CasesArchive of Old Cases

Case No : 1395 Date 2024-07-15

  • Courtesy of Seung-Jin Yoo, Yo Won Choi / Hanyang Universitiy Medical Center
  • Age/Sex 44 / F
  • Chief ComplaintDyspnea Underlying acute promyelocytic leukemia
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Diagnosis With Brief Discussion

Diagnosis
ATRA syndrome (Differentiation syndrome)
Radiologic Findings
Fig 1. Chest PA shows central ground glass opacity (GGO) at the right lung and septal lines at both lungs.
Fig 2-4. CT scans reveal central GGO at the right upper lobe and interlobular septal thickening at the right middle lobe, right lower lobe, and left upper lobe. A small amount of pericardial effusion and bilateral pleural effusion are present.

Our patient underwent ATRA therapy due to APL 10 days before taking the chest radiograph in Figure 1.
Brief Review
Acute promyelocytic leukemia (APL) is one of the subtypes of acute myeloid leukemia (AML) and is a rare disease that occurs in 10-15% of patients with AML. ATRA is used as an accepted therapy for APL. Formerly known as ATRA syndrome, differentiation syndrome (DS) is a potentially life-threatening complication of ATRA that usually emerges during the first days or weeks of ATRA therapy. Dyspnea, pulmonary infiltrates, pleural effusion, fever, weight gain, peripheral edema, hypotension, and acute renal failure are the hallmarks of DS. DS occurs in approximately 20-25% of all APL patients undergoing ATRA and is treated with intravenous dexamethasone or by considering discontinuation of ATRA. The mortality rate of DS is known to be 5-30%.
Radiologic features of DS is not specific and similar to congestive heart failure with pulmonary edema: these include cardiomegaly, widening of the vascular pedicle width, increased pulmonary blood volume, peribronchial cuffing, ground-glass opacity, septal lines, and pleural effusion.
References
1. Jung JI, Choi JE, Hahn ST, Min CK, Kim CC, Park SH. Radiologic features of all-trans-retinoic acid syndrome. AJR Am J Roentgenol. 2002 Feb;178(2):475-80. doi: 10.2214/ajr.178.2.1780475. PMID: 11804921.
2. Yilmaz, M., Kantarjian, H. & Ravandi, F. Acute promyelocytic leukemia current treatment algorithms. Blood Cancer J. 11, 123 (2021). https://doi.org/10.1038/s41408-021-00514-3
Keywords

No. of Applicants : 60

▶ Correct Answer : 34/60,  56.7%
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - The University of Tokyo Hospital , Japan JUN KANZAWA
  • - Shiga University of Medical Science , Japan AKITOSHI INOUE
  • - Kyoto University , Japan AKIHIKO SAKATA
  • - Kyoto City Hospital , Japan YUSUKE UTSUNOMIYA
  • - , Korea (South) DONG-HO BANG
  • - Healthy Longevity Medical Center , Japan SHIN-ICHI CHO
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Other , Korea (South) SEONGSU KANG
  • - Other , Korea (South) DOWOO KIM
  • - Seoul Medical Center , Korea (South) HYUK GI HONG
  • - Other , Korea (South) HYEJOO PARK
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - , Korea (South) KI EON KWON
  • - , Japan YOSHIKI ISHII
  • - Ajou University Hospital , Korea (South) YOU NA KIM
  • - Other , Korea (South) CHAEHUN LIM
  • - Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
  • - , Korea (South) HEONSEOK LEE
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - Avrasya Hospital/ISTANBUL , Turkey MURAT ULUSOY
  • - Osaka metropolitan university Hospital , Japan TATSUSHI OURA
  • - Other , Korea (South) SEOL A LEE
  • - Korea University Anam Hospital , Korea (South) KYU-CHONG LEE
  • - Paras hospital, Panchkula , India SHALEEN RANA
  • - Kyoto University , Japan SHO KOYASU
  • - Fukuoka university , Japan KEISUKE SATO
  • - , Japan YUMI MAEHARA
  • - Toyota Kosei Hospital , Japan YUKI HAYASHI
  • - The Catholic University of Korea Yoeuido St. Mary , Korea (South) CHAWOONG JEON
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - University of Yamanashi , Japan KOJIRO ONOHARA
  • - Juntendo University , Japan YUTAKA IKENOUCHI
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Correct Answer as Differential Diagnosis : 2/60,  3.3%
  • - Secomedic Hospital , Japan FUMINORI MIYOSHI
  • - University of Yamanashi , Japan HIROYUKI MORISAKA
▶ Semi-Correct Answer : 3/60,  5.0%
  • - McGill University Health Center , Canada ALEXANDRE SEMIONOV
  • - , Japan KENTARO KOTANI
  • - Dokkyo Medical University , Japan HIROAKI ARAKAWA
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