66 year old female presented to the ED complaining of worsening headache, dizziness, and shortness of breath for 1 week, and also new multiple areas of ecchymosis.
Patient was admitted and treated for CHF. While in the hospital, patient was found to have elevated WBC count with blasts on peripheral smear, hemoglobin 6.7, and platelet count of 7,000. Bone biopsy was performed and she was diagnosed with acute promyelocytic leukemia (APL) and started on all-trans retinoic acid (ATRA) therapy.
Two days after starting ATRA her shortness of breath exacerbated, despite continued treatment for CHF. Radiographically her pulmonary edema pattern also worsened, and it was thought it may be secondary to differentiation syndrome (previously called ATRA syndrome).1
After discontinuing ATRA treatment, patient's symptoms improved and the discharge chest radiograph demonstrated no acute pulmonary disease.
The differential of worsening pulmonary edema pattern included: CHF exacerbation, pneumonia/aspiration, ARDS, and diffuse pulmonary hemorrhage.