Acute promyelocytic leukemia; early diagnosis is the key to survival

Acute promyelocytic leukemia, a subtype of acute myelogenous leukemia characterized by an abnormal accumulation of immature granulocytes called promyelocytes, is a feared oncologic emergency. Currently, management of acute promyelocytic leukemia with supportive transfusions, to correct underlying coagulopathy, and all-trans retinoic acid, in combination with chemotherapy, can lead to complete remission in 80% to 90% of cases. However, early mortality from pulmonary or intracranial hemorrhage remains high if cases are late presenting or treatment is delayed. We report the case of a 23-year-old woman who presented to her local emergency department (ED) with headache, chills, epistaxis, dry cough, and fever. The emergency physician diagnosed her with a "viral illness" and discharged her home on symptomatic treatment. One week later, she developed easy skin bruising and hemoptysis. In a second visit, she was diagnosed with acute leukemia based on these clinical features in addition to an abnormally elevated white blood cell count and admitted to the hospital. The following day the patient was transferred to our ED for expert cancer care; additional laboratory investigations revealed progressive anemia, thrombocytopenia, and coagulopathy. A review of her peripheral smear showed abundant promyelocytes consistent with a diagnosis of acute promyelocytic leukemia (APL), and treatment with supportive blood transfusions and all-trans retinoic acid (ATRA) was started. Given her complaints of headache in the setting of thrombocytopenia and coagulopathy, she underwent a computed tomographic (CT) scan of brain, and the scan results revealed an intracranial hemorrhage. The patient's condition progressively deteriorated, and on day 5 of her hospitalization, she died of complications from the intracranial hemorrhage.