Paralytic ileus occurring during treatment with all-trans retinoic acid for acute promyelocytic leukemia

Figure 1. A, Abdominal x-ray photograph taken on October 8, 2001. Gas was present in the small intestine. B, Abdominal x-ray photograph taken before colonoscopy on November 6, 2001. Marked colonic gas was detected. We report a case of acute promyelocytic leukemia (APL) demonstrating paralytic ileus during treatment with all-trans retinoic acid (ATRA). A 68-year-old Japanese man with APL was referred to our hospital on January 9, 2001. Peripheral blood cell counts on admission were as follows: the white blood cell count (WBC) was 1.8 109/L (banded neutrophils 2%, segmented neutrophils 18%, lymphocytes 76%, monocytes 4%); the hemoglobin (Hb) concentration was 11.7 g/ dL; the platelet count (Plt) was 103 109/L. On January 29, 2001 treatment with ATRA was begun at a dose of 45 mg/m2 per day (70 mg/day). On day 14 of ATRA treatment, the patient showed a high fever and erythema on the bilateral elbows, knee joints, and hands. ATRA was stopped and erythema disappeared gradually. Bone marrow aspiration on February 27, 2001, demonstrated complete remission. Subsequent consolidation chemotherapy was refused by the patient and his family. The patient was discharged on March 3, 2001, and was regularly followed as an outpatient. In August 2001, APL relapsed. ATRA was started again on September 23, 2001, at a dose of 70 mg/day. Five days later, the patient developed pneumonia in the right lung and was hospitalized again. Laboratory findings on admission were as follows: WBC was 1.5 109/L (banded neutrophils 4%, segmented neutrophils 17%, lymphocytes 74%, monocytes 5%); Hb was 12.2 g/dL; Plt was 128 109/L. The criteria for disseminated intravascular coagulation were not fulfilled (fibrinogen was 210 mg/dL, fibrin degeneration product level was 10 g/mL, D-dimer was 0.68 g/mL, and 2-plasmin–inhibitor-plasmin complex was 2.4 g/mL). Pneumonia improved, but on day 11 of ATRA treatment, the patient developed painful erythema at the same sites as previously. The erythema disappeared gradually with administration of prednisolone (20 mg/day), but on day 15, the patient Paralytic Ileus Occurring during Treatment with All-trans Retinoic Acid for Acute Promyelocytic Leukemia