Recurrent Arterial Thrombosis as a Presenting Feature of a Variant M3-Acute Promyelocytic Leukemia

Acute promyelocytic leukemia presenting as recurrent venous and arterial thrombotic events: a case report and review of the literature

Acute promyelocytic leukemia (APL) is a distinct subtype of acute myeloid leukemia characterized by a translocation of chromosomes 15 and 17, creating an alternation in the retinoic acid receptor-alpha (RAR-alpha) gene. This leads to excessive medullary production of promyelocytic blasts, which are frequently associated with the hemorrhagic complications seen in APL. In contrast, APL-associated thrombosis occurs much less frequently and is an underappreciated life-threatening manifestation of the disease. Most thrombotic events occur during induction chemotherapy with all-transretinoic acid and are rarely seen as the initial presentation on APL. Here we report an exceedingly rare case of a patient with recurrent venous and arterial thrombotic events, including deep vein thrombosis, bilateral segmental pulmonary embolism, an ischemic stroke, splenic infarcts, and renal infarcts, later found to have APL. We aim to discuss the most recent understanding of the pathogenesis of APL-associated thrombosis and to summarize the literature of this rare presentation of APL.

Acute leukemia presenting as acute lower limb ischemia

Objectives: Acute lower limb ischemia (ALLI) is a common vascular emergency. However, ALLI presenting as the initial symptom of acute leukemia (AL) is scarce. Here we present a case of ALLI in the setting of acute myeloid leukemia (AML) while systematically reviewing the current literature to withdraw conclusions about the management, prognosis, and treatment for this atypical presentation of AL. Methods: We conducted a systematic electronic research according to Preferred Reporting Items for Systematic Review and Meta-Analysis protocol (PRISMA) for articles published from January 1981 up to January 2021 concerning ALLI in the setting of acute leukemia (AL). Patients' baseline characteristics were recorded and nine outcomes of interest were studied. Results: Twenty-six individuals, 16 males with a mean age of 46.3 years (±20) were included in this review. The diagnosis included 13 AML patients (50%), 11 acute promyelotic leukemia (APL) (42.3%) and two acute lymphoblastic leukemias (ALL) (7.7%). Treatment varied among nine different regimens. Four patients were treated with chemotherapy alone (15.4%), four with thrombectomy alone (15.4%), and 11 with a combination of chemotherapy and thrombectomy (42.3%). Eight major amputations were recorded (30. 8%). Thirty-day mortality was 35.7%. Forty-eight peripheral thrombotic events were recorded with 12 patients suffering recurrent thrombotic events. Conclusion: ALLI as the presenting symptom of AL is a rare condition that carries significant mortality and amputation rates. Timely diagnosis is crucial concerning short-term survival and limb salvage. APL, despite being the rarest form of AL, represented a significant proportion of the patient population in this review. The role of leukostasis in the disease's progression and the efficacy of leukapheresis as a treatment regimen should be further investigated through case-control studies.

Acute Promyelocytic Leukemia Presenting as Bilateral Acute Limb Ischemia and ST Elevation Myocardial Infarction: A Case Report

Acute myelogenous leukemia (AML) is one of the most common hematologic malignancies. Among them, acute promyelocytic leukemia (APL) is well known for its coagulopathies. Bleeding secondary to disseminated intravascular coagulation, is a common initial presentation and carries a high risk for mortality if left untreated. Thrombotic complications are uncommon and can be related to treatment with chemotherapeutic agents. Large artery thrombosis is very rare, and standardized management remains elusive given the classic revascularization techniques carry a significant risk of re-thrombosis, as well as high risk for mortality given the multiple surgical and percutaneous interventions that are attempted. A multidisciplinary approach is necessary in these cases to carefully weigh the risk and benefits as the classical approach to revascularization and acute arterial thrombosis could potentially cause harm.

Deluging Thrombosis: An Unusual Presentation of Acute Promyelocytic Leukemia

Acute promyelocytic leukemia (APML) patients are prone to thrombosis. However, thrombosis at presentation is rare in APML. Our patient presented with thrombosis and cytopenia, and the clinical diagnosis was of paroxysmal nocturnal hemoglobinuria. However, subsequent peripheral blood smear and bone marrow study confirmed the diagnosis of APML. The patient was successfully managed with anticoagulation, arsenic trioxide, and all-trans retinoic acid.