Case 2

A 24-year-old man presented with fever, chills, and cough. After evaluation at another hospital revealed circulating white blood cells, he was referred to this hospital for further evaluation and therapy. At the time of hospital admission, the patient had a fever of 38.3°C. Cervical, inguinal, and axillary lymphadenopathy was present. Examination of the chest revealed tubular breath sounds and egophony at the right lung base and over the right anterior part of the chest. Both the liver and the spleen were moderately enlarged. The WBC count was 11,800/cu mm with 53 percent blasts, and there were 67,(KK) platelets. Bone marrow biopsy specimen con­firmed diagnosis of acute lymphocytic leukemia. A chest roentgen­ogram showed an infiltrate in the right midlung field (Fig 2). An arterial blood gas determination, obtained while the patient breathed ambient air, showed a pll of 7.52, Pco2 of 29 mm Hg, and P<>2 of 61 mm Hg. Cardiac and renal function were normal.

Mezlocillin and gentainicin were administered, but the patient remained febrile. Because of continued fever, dyspnea, and pro­gressive lung infiltrates, fiberoptic bronchoscopy was performed on the third hospital day. The airways appeared normal and no abnormal secretions were seen. Brushings, lavage specimens, and three transbronchial biopsy specimens were obtained from the right lower lobe. Scattered lymphoid leukemic cells were seen in the bronchial lavage fluid but not in the brushings. The transbronchial biopsy specimens showed many atypical immature lymphoid blasts intra­vascular!, as well as in the interstitium and perivascular spaces. Special stains for acid-fast bacilli, bacteria, including Legionella, fungi, and P carinii were negative as were numerous cultures.
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FIGURE 2. Chest roentgenogram from patient 2 showing a right midlung field infiltrate.

The patient was treated with two successive courses of daunoru- biein, vincristine, and prednisone. The roentgenographic infiltrates grew worse initially; however, the began to resolve one week after chemotherapy was begun. Three weeks after treatment, neutrope­nia developed and the roentgenographic infiltrates cleared com­pletely. The patient was discharged from the hospital in complete remission 28 days after admission.

Case 3

A 63-year-old man saw his physician because of increasing dyspnea and chest congestion. A CBC count revealed main blasts and a bone marrow biopsy specimen led to the diagnosis of acute myelogenous leukemia. The patient was referred to this hospital for further therapy.

At the time of hospital admission he was found to he in moderate respiratory distress with a blood pressure of90/50 mm Hg. Crackles were heard over the right upper lung and over both lung bases. The WBC count was 23,300/cu mm with 44 percent blasts and the platelet count was 123,000/cu mm. A chest roentgenogram showed patchy ill-defined densities in the right upper lung field (Fig 3).

Figure 3. Chest roentgenogram from patient 3 showing patchy right lung infiltrates.

Fiberoptic bronchoscopy was performed on the third hospital day. Bronchial brushings, lavage specimens, and three transbronchial biopsy specimens were obtained from the right upper lobe. Cyto­logic examination of the brushings was negative, and the lavage fluid showed rare blasts and considerable blood suggesting that the blasts may have been present secondary to hemorrhage. The transbronchial biopsy specimens showed an interstitial, subbron- chial, and subbronchiolar leukemic infiltrate. Special stains were negative for acid-fast bacilli, Legionella, fungi, and P carinii. Cultures provided no evidence of bacterial, fungal, or mycobacterial infection.
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Cytarabine was administered by continuous intravenous infusion beginning on the sixth hospital day and for 21 consecutive days thereafter w ithout apparent benefit. A regimen of daunorubicin, cytarabine, and 6-thioguanine was begun on the 27th hospital day. Three weeks later neutropenia developed and the right upper lobe infiltrate cleared completely. The patient was discharged from the hospital in complete remission on the 72nd day after admission.