Case 1

A 20-vear-old woman was admitted to the Hospital of the University of Pennsylvania, Philadelphia, because of fever. Six months before hospital admission a complete blood cell (CBC) count, obtained because of chronic nasal congestion, disclosed a white blood cell (WBC) count of38,000/cu mm with many immature forms. A bone marrow biopsy specimen was diagnostic of acute myelomonocytic leukemia (AML-M4). A complete remission was achieved using standard induction chemotherapy (daunorubicin [Daunomycin], cytarabine [Ara-C], and 6-thioguanine). However, three months later a blood smear again revealed circulating blast cells. During a second hospitalization, a partial remission was induced using M-AMSA and high-dose cytarabine. She was dis­charged from the hospital two weeks before the current hospitali­zation to complete a course of amphotericin В that was prescribed for candidemia.

t the time of hospital admission, her temperature was 38.3°C. Palatal petechiae were present. Her lungs were clear. The WBC count was 40,200/cu mm with 95 percent blasts; platelet count was 79,000/cu mm. A chest roentgenogram showed no infiltrates. Piperacillin and gentamicin were added to amphotericin B. How­ever she remained febrile.
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On the third hospital day the patient complained of a new cough and was noted to be tachypneic. The WBC count was 42,100/cu mm, 90 percent of which were blasts. An arterial blood gas determination, obtained while the patient breathed room air, showed a pH of 7.50, Po, of 77 mm Hg, and Pco2 of 33 mm Hg. There was no clinical evidence of fluid overload. Because a chest roentgeno­gram revealed a new infiltrate in the left lower lobe, fiberoptic bronchoscopy was performed. Bronchial lavage and brushings revealed virtually KM) percent leukemic blast cells with scattered alveolar macrophages (Fig 1, A). Multiple transbronchial biopsy specimens showed an interstitial and peribronchial infiltrate of blasts (Fig 1, B). Special stains for acid-fast bacilli, fungi, Pneumo­cystis carinii, and Legionella (direct fluorescent antibody technique) were negative, and cultures showed no ev idence of infection. Bone marrow biopsy specimen showed a hypercellular marrow packed with blasts (Fig 1, C).

FIGURE 1. Photomicrographs illustrating the path-ologic changes in patient 1. A (upper left). Cv- tospin preparation ofbronehoalveolar lavage fluid is packed with large atypical mononuclear cells. The cells have irregular clefted nuclei, some with nucleoli (blasts). There are scattered macrophages with abundant cytoplasm and anthracotic pigment (original magnification x 1(XX)). В (rig/if). Trans- bronchial biopsy specimen showing an interstitial and perivascular infiltrate of atypical large blasts (original magnification X 200). С (lower left). Bone marrow biopsy specimen obtained on the same day as the bronchoscopy showing evidence of relapse. Virtually all of the cells are mvelomono- cytic blasts. Note numerous mitoses (original magnification x 1000).

All antibiotic therapy was discontinued and the patient was treated with an experimental chemotherapeutic agent, homohar- ringtonine. Although her chest roentgenographic infiltrates pro­gressed initially, they cleared completely by the 14th day after the onset of chemotherapy as she became neutropenic. She was discharged from the hospital 38 days after admission having achiev ed a partial remission of her leukemia.