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Treatmen t is initiated with all-trans-retinoic acid (ATRA) and daunorubicin. Ten days later, the patien t reports worsening dyspnea, cough . fever. and lower extremity swell-ing. Laboratory eval uation reveals leukocyte count of 1 7 .800/ pl. Chest x-ray is ob-tai ned and is shown below.
What would be the next most appropriate step in the management of this patient?
- Diuresis
- Echocardiogram
- Infectious workup and initiation of broad-spectrum antibiotics
- Infectious workup and initiation of dexamethasone
- Reinduction with daunorubicin, cytarabine, and arsenic trioxide (ATO)
Medicine
D. Presentation is most consistent with APL differentiation syndrome that can be associ-ated with the use of ATRA or ATO. Prompt initiation of dexamethasone is considered the treatment of choice, and temporary discontinuation of ATRA or ATO can be considered in the most severe cases pending improvement. APL differentiation syndrome presents with fever, hypoxemia, pulmonary in-filtrates, hypotension, renal dysfunction, edema, and weight gain, which can mimic sepsis. Infectious workup is indicated to rule out an underlying infection (Blood. 2009;1 13( 4):775, Blood. 2000;95(1):90).
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