Leukemic Pleural Effusion in Acute Promyelocytic Leukemia: A Case Report

Narae Hwang; Soongki Roh; Ji Yeon Ham; Jang Soo Suh

doi:10.3343/lmo.2018.8.1.24

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Hwang, Roh, Ham, and Suh: Leukemic Pleural Effusion in Acute Promyelocytic Leukemia: A Case Report

Original Article

Lab Med Online 2018;8(1):24-28.

Published online: 19 January 2018

DOI: https://doi.org/10.3343/lmo.2018.8.1.24

Leukemic Pleural Effusion in Acute Promyelocytic Leukemia: A Case Report

Narae Hwang, M.D., Soongki Roh, M.D., Ji Yeon Ham, M.D., Jang Soo Suh, M.D.

Department of Clinical Pathology, Kyungpook National University School of Medicine, Daegu, Korea

Corresponding author: Jang Soo Suh Department of Clinical Pathology, Kyungpook National University School of Medicine, 680 Gukchebosang-ro, Chung-gu, Daegu 41944, Korea Tel: +82-53-200-5293, Fax: +82-53-200-3367, E-mail: suhjs@knu.ac.kr

Received 15 June 2017 Revised 26 September 2017 Accepted 26 October 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Acute promyelocytic leukemia, Leukemic pleural effusion, PML-RARA

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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).

Table 1.

Reported cases of pleural infiltration in AML

Case No.	Age/Sex	WBC (×10⁹/L)	Hb (g/dL)	Platelet (×10⁹/L)	FAB	BM∗	FCM	FISH or RT-PCR	EMD	P	R
1	34/M	NA	NA	NA	M3	N	ND	RT-PCR PML-RARA (+)^†	Pleura, heart, pericardium	D	[7]
2	39/M	4.52	14	212	M3	N	PF	ND	Pleura	CR	[4]
3	53/M	11.5	8	103	M2	Y	ND	FISH RUNX1-RUNX1T1 (+)	Pleura	CR	[8]
4	19/M	6.9	9.5	94	M5	Y	BAL	ND	BAL, CSF	CR	[9]
5	4/M	NA	NA	NA	M2	Y	ND	FISH Lung Bx: RUNX1-RUNX1T1(+)	Lung	CR	[10]

^∗ BM involvement;

^† PML-RARA (+) in peripheral blood Abbreviations: N, No; Y, Yes; ND, not done; NA, not available; CR, complete remission; FCM, flow cytometry; P, prognosis; R, reference; D, dead; PF, pleural fluid; BAL, bronchoalveolar lavage; EMD, extramedullary disease; FAB, French-American-British classification; Bx, biopsy.

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