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Arsenic-trioxide/tretinoin Differentiation syndrome: case report

A 51-year-old man developed differentiation syndrome during treatment with arsenic-trioxide and tretinoin for acute promyelocytic leukaemia [routes and dosages not stated]. The man presented with sudden loss of vision. Two weeks before the presentation, he started receiving induction therapy with arsenic-trioxide [andarsenic trioxide] and tretinoin [all-trans-retinoic acid] for acute promyelocytic leukaemia. Subsequently, his hospital stay was complicated with neutropenic fever. Therefore, he was commenced on cefepime, vancomycin, voriconazole and aciclovir [acyclovir] for prophylaxis. His laboratory test showed pancytopenia. His visual activity was count finger at three feet in both eyes, and intraocular pressures were 10mm Hg OD and 11mm Hg OS. His pupils were round and reactive without any pupillary defect. Colour plates were one of eight OU with 50% brightness desaturation without red desaturation in the right eye. His slit-lamp examination was negative for inflammation. His dilated fundus examination showed bilateral choroidal effusions with diffuse serous retinal detachments (RD) involving the macula without vitritis, also white-centred intraretinal haemorrhages along with peripapillary and superior and inferior arcade distributions in both the eyes. Subsequently, his optical coherence tomography (CT) scan showed irregular inner retinal surface and subretinal fluid with septae with loss of the ellipsoid zone. Thereafter, he developed tachycardia, fever, odynophagia, productive cough with wheezing, and marked peripheral oedema in the upper extremities. Based on the finding, he was diagnosed with differentiation syndrome secondary to arsenic-trioxide and tretinoin therapy. Therefore, the man’s treatment with tretinoin was held for two days, and he was treated with dexamethasone. Thereafter, his systemic and visual symptoms improved. Following two weeks, his condition completely resolved. Six weeks later, repeated optical CT scan showed a flat retina with persistent disruptions of the ellipsoid zone, also his visual activity improved from count fingers to 20/40 OU. Hua HU, et al. Acute Promyelocytic Leukemia With Sudden Vision Loss. JAMA Ophthalmology 138: 206-207, No. 2, Feb 2020. Available from: URL: http:// doi.org/10.1001/jamaophthalmol.2019.4838

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Reactions 12 Dec 2020 No. 1834