Lab Med Online.  2018 Jan;8(1):24-28. 10.3343/lmo.2018.8.1.24.

Leukemic Pleural Effusion in Acute Promyelocytic Leukemia: A Case Report

• Hwang N
• Roh S
• Ham JY
• Suh JS

• KMID: 2398416
• DOI: http://doi.org/10.3343/lmo.2018.8.1.24

Abstract

In patients with acute myeloid leukemia (AML), pleural effusion may be attributed to various factors, including infection, hypoalbuminemia, and renal failure. However, leukemic infiltration of the pleural fluid is rarely reported and poorly understood. Extramedullary diseases have been reported with increasing frequency as the survival rates of patients with AML have increased. However, the reported prognostic effects of leukemic pleural effusion in patients with AML range from none to a worse prognosis. Here, we report a case of acute promyelocytic leukemia (APL) in a patient exhibiting leukemic pleural effusion with fluorescence in situ hybridization (FISH) results indicating the presence of the PML-RARA fusion gene. A 52-year-old man presented with pancytopenia, dyspnea, and fever. He had a medical history of hypertension, end-stage renal disease, and hepatitis B virus-related liver cirrhosis. A peripheral blood smear revealed the presence of multiple abnormally hypergranular promyelocytes. White blood cell differential counts were not performed due to severe pancytopenia. A bone marrow examination, immunophenotyping analysis, and cytogenetic and molecular studies revealed APL. The patient was treated with all-trans retinoic acid immediately after abnormal promyelocytes were observed in the peripheral blood smear, but induction chemotherapy was delayed because of his poor condition. His persistent dyspnea and abdominal discomfort led to a thoracentesis and the observation of abnormal promyelocytes that were positive for PML-RARA fusion gene by FISH. To our knowledge, this is the first report of leukemic pleural infiltration with PML-RARA fusion gene-positivity via FISH.

Keyword

Acute promyelocytic leukemia; Leukemic pleural effusion; PML-RARA

MeSH Terms

Bone Marrow Examination
Cytogenetics
Dyspnea
Fever
Fluorescence
Granulocyte Precursor Cells
Hepatitis B
Humans
Hypertension
Hypoalbuminemia
Immunophenotyping
In Situ Hybridization
Induction Chemotherapy
Kidney Failure, Chronic
Leukemia, Myeloid, Acute
Leukemia, Promyelocytic, Acute*
Leukemic Infiltration
Leukocytes
Liver Cirrhosis
Middle Aged
Pancytopenia
Pleural Effusion*
Prognosis
Renal Insufficiency
Survival Rate
Thoracentesis
Tretinoin
Tretinoin

Figure

• 

  Fig. 1. Abnormal promyelocytes with multiple Auer rods in the bone marrow (Wright's stain ×1,000) (A) and conventional bone marrow chromosome analysis result showing a 47,XY,+add(5)(q11.2)x2,der(5;8) (q10;p10),del(7)(q32), t(15;17)(q22;q21) [21] karyotype (B).

• 

  Fig. 2. Abnormal promyelocytes with multiple Auer rods in pleural fluid (Wright's stain ×1,000) (A) and dual-color, dual-fusion fluorescence in situ hybridization analysis on interphase cells showing two green signals, indicating the t(15;17) translocation (B).

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