Diffuse alveolar hemorrhage during induction therapy for acute myeloid leukemia with inv(16)(p13.1q22)

A 52-year-old man with no significant medical history developed extreme fatigue. His laboratory data showed anemia (hemoglobin concentration 6.3 g/dL), thrombocytopenia (platelet count 62,000/µL) and increased leucocyte (white blood cell 23,700/µL) with 54% circulating blast cells. After bone marrow aspiration, the diagnosis of acute myeloid leukemia (AML) with inv(16)(p13.1q22);CBFB-MYH11 and AML M4Eo was made according to 2016 WHO classification and FAB classification, respectively. His general condition was stable and pretreatment thoracic computed tomography (CT) image showed no abnormal shadow at the lung on the day before the beginning of induction chemotherapy with idarubicin and cytarabine (3 + 7) (Fig. 1a). On the second day of the induction therapy, he showed a little bloody sputum. On day 3, he developed a low-grade fever over 37.5 °C and fell into acute respiratory failure due to hemoptysis. Oxygen support of 4 L/min with nasal cannula was required to maintain arterial oxygen saturation above 95%. Chest radiograph showed bilateral pulmonary consolidation and air bronchogram (Fig. 1b). Thoracic CT showed diffuse ground-glass opacities and interlobular septal thickening suggesting that the patient suffered from diffuse alveolar hemorrhage (DAH) (Fig. 1c). His blood count results were as follows: white blood cells, 7900/µL with 31% blasts; hemoglobin concentration, 7.5 g/dL; platelets count, 35,000/µL. The blood biochemistry and the coagulation profile did not suggest tumor lysis syndrome and disseminated intravascular coagulation, respectively. Sputum and blood culture showed negative results including mycobacterium. Cytomegalovirus (CMV) antigenemia test, plasma β-d-glucan, serum aspergillus antigen and T-SPOT.TB were all negative. Based on these findings, the diagnosis of non-infectious DAH was reached. Induction chemotherapy was discontinued and methylprednisolone pulse therapy was initiated. We started to administrate ceftazidime and levofloxacin for febrile neutropenia. Bloody sputum and respiratory failure were improved the next day after steroid-pulse therapy. And an abnormal shadow in thoracic CT also completely diminished after steroid therapy for 7 days (Fig. 1d). He completely recovered from respiratory failure and his leukemia was in complete remission after induction chemotherapy. He received three cycles of high-dose Ara-C with methylprednisolone to prevent hemoptysis. He never showed hemoptysis and kept cytogenetic complete remission for 1 year and a half. He relapsed and received re-induction chemotherapy with daunorubicin, cytarabine and methylprednisolone. He underwent allogeneic stem cell transplantation in the second complete remission and finally achieved complete molecular response without graft-versus-host disease and hemoptysis after transplantation.

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