TableISummaryofhaematologicalandradiographic ID: 107740
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aminoglycoside,asinfectiouspneumoniawasbothclinic-allyandradiologicallysuspected,andthencarbapenemesandglucopeptides.Onepatientalsoreceivedcotrimazoleandanotherganciclovir,basedonHRCTÞndings,whichPneumocystiscariniiandcytomegaloviruspneu-moniarespectively.Allpatientsunderwentbronchoscopywithbronchoalveolarlavage(BAL).Cultural,serologicalandmolecularexaminationsonblood,urine,faecesandBALsampleswererepeatedlynegativeforbacterial,fungal,viralandprotozoanagents.CytologicalanalysisofBALsampleswasunremarkable.Culturalandmolecularexam-inationsoflungtissuesamplesforinfectiousagentswereLungspecimenswerecollectedbytransbronchialbiopsyfrompatient4,viavideotorachoscopictorachotomyfrompatient2,andatautopsyfromtheremainingtwopatients.Thehistologicalsampleswerecollectedfromdifferentlocationsforeachlung.PulmonaryinÞltrationofleukaemicblastswasrevealedbyMayÐGrunwaldÐGiemsastaining,andconÞrmedbyimmunohistochemicalanalysisusinganalkalinephosphataseantialkalinephosphatase(APAP)techniqueandantimyeloperoxidase(anti-MPO)antibodies.AllpatientsincludedinthisstudywereevaluatedwithstandardradiographyandwithHRCTofthechest.ThelongesttimeintervalbetweenchestradiographyandHRCTscanningwas1d.ThelongesttimeintervalbetweenHRCTscanningandhistologicalsampleacquisitionwas2d.TheHRCTtechniqueused(1-mmslice,10-mmincrements,inspiration)waspreviouslydescribedbyHeusseletal(1999).FortheinterpretationofthechestHRCTscans,theimagingcriteriausedwerethosesuggestedbyWebbetal(1988)andaccordingtothelungdivisionofWeibelPatients1and4weretreatedwithchemotherapy,includinganthracycline,cytosinearabinosideandetopo-side,whilepatient2receivedallretinoicacidandanthracycline.AllfourpatientsdiedofrespiratoryinsufÞ-ciency.Patients1and4died2and5d,respectively,afterthebeginningoftherapy.Patient3diedofsuddenrespir-atoryarrest,thedayaftertheHRCTscan.Despiteacompleteresolutionofthepulmonarypattern,patient2diedond19fromthebeginningofchemotherapyfromstaphylococcalsepsis.RESULTSANDDISCUSSIONThemainclinicalfeatures,standardradiographicandHRCTÞndingsofthefourAMLpatientsaresummarizedinTableIandinFig1AÐD.AlthoughthemostfrequentradiographicÞndingisanair-spacediseasewithadiffuseinterstitialreticularpatternincasesofhyperleucocytosis,inpulmonaryleukaemiawithoutleucocytosisacommonordistinctivepatternofHRCTÞndingsmaynotbeclearlyidentiÞed,raisingproblemsofdifferentialdiagnosis,especiallywiththeradiographicfeaturesofinfectiousdiseaseinneutropenicHRCTÞndingsinviralpneumoniashowinter-stitial,nodularoralveolarprocessplusground-glassorreticularopacityAnair-spacediseasewithorwithout TableI.SummaryofhaematologicalandradiographicÞndingsinfourAMLpatientswithleukaemicpulmonaryinÞltrates.Patientnumbersex/age(years)WBCcount/l)/peripheralblastcells(%)StandardradiographicÞndingsHRCTÞndingsAir-spaceopaciÞcationPatchyconsolidationGround-glassopaciÞcationSmallnodulesCylindricalbronchiectasis1M/51AML-M128/6Bilateralpatchy,sometimesconßuent,multifocalairspacedisease++++/Ð2F/73AML-M336/15Bilateraldiffuseopacities,sometimesconßuent,withprevalenceoflobarandbronchopneumoniapattern.Slightbilateralpleuraleffusions.++++3M/52RAEB-t16/10Normal+/Ð++4M/64AML-M412/11Bilateraldiffuseinterstitialpattern+++++/Ð++++,stronglyrepresented;+,represented;+/Ð,weaklyrepresented;emptybox,absent.ShortReport2003BlackwellPublishingLtd,BritishJournalofHaematology:1058Ð1061 consolidationareas,cavitationprocessandeffusionsshouldraisethesuspicionofbacterialpneumonia.Fungalpneu-moniashowsrapidlyprogressivenodularopacity,Ôdrowned-lobeÕ,cavitation,aircrescentormiliarypattern,andahalosignAlesscommonÞndingmayberepresentedbysepticembolismofthelungwithmultiple,smallnoduleswithcavitationandair-bronchograms,andthickseptalInthevastmajorityofpatientswithpneumoniaHRCTÞndingsincludediffuse,bilateral,symmetric,ÞnelygranularorreticularinÞltratesthatmaybeinterstitialormoreair-spaceinnature(HeusseletalInleukaemicpatients,non-infectiousdiseases(haemorrhage,cryptogenic-organizingpneumonia,pul-monarychronicgraft-versus-hostdisease,adultacuterespiratorydistresssyndrome)mayalsobeassociatedwithpulmonaryinÞltrateswithasimilarradiologicalappearance(Primack&Muller,1994).ThepresentstudyprovidestheÞrstdescriptionofthespectrumofHRCTimagingÞndingsinAMLpatientswithpulmonaryleukaemia.Itsupportstheinclusionofpulmon-aryleukaemiainthedifferentialdiagnosisofpossiblecausesofpulmonaryinÞltratesinnon-hyperleucocytosicpatients,evenwhenstandardchestradiographyisnegative.HRCT,incombinationwithHRCT-guided-bronchialandvideo-thoracoscopicbiopsies,mayhelpintheearlyidentiÞcationofpulmonaryleukaemiawithpossible,rele-vantclinicalconsequences.ResearchgrantsupportwasreceivedfromtheAssociazioneItalianaperlaRicercasulCancro(A.I.R.C.,Milan,Italy)toGeller,R.A.(1971)Acuteleukemiapresentingasrespiratorydis-ArchivesofPathology,573Ð576.Heussel,C.P.,Kauczor,H.U.,Heussel,G.E.,Fischer,B.,Begrich,M.,Mildenberger,P.&Thelen,M.(1999)Pneumoniainfebrileneutropenicpatientsandinbonemarrowandbloodstem-celltransplantrecipients:useofhigh-resolutioncomputedtomo-JournalofClinicalOncology,796Ð805.Heyneman,L.E.,Johkoh,T.,Ward,S.,Honda,O.,Yoshida,S.&Muller,N.L.(2000)Pulmonaryleukemicinfiltrates:high-resolutionCTfindingsin10patients.AmericanJournalofRoent-,517Ð521.Kovalski,R.,Hansen-Flaschen,J.,Lodato,R.F.&Pietra,G.G.(1990)Localizedleukemicpulmonaryinfiltrates.Diagnosisbybronchoscopyandresolutionwiththerapy.,674Ð Fig1.HRCTÞndingsinpatientswithAMLandleukaemicpulmonaryinÞltrates.(A)Conßuentair-spaceopaciÞcationswithpatchyconsol-idationandperibronchovasculardistributionintherightlung.Ground-glassopaciÞcationintheupperleftlobe(patient1).(B)Bilateralareasofpatchyconsolidationwithcylindricalbronchiectasisandleftbasalground-glassattenuation(patient2).(C)Multiplesmallnodules,mainlysubpleural,intherightlungandreticularopacities(patient3).(D)Bilateralground-glassopacities,interstitialmarkingsandpatchyareasofconsolidation(patient4).ShortReport2003BlackwellPublishingLtd,BritishJournalofHaematology:1058Ð1061 Nelson,S.C.&Ravreby,W.D.(1980)Respiratoryfailureandacute,799Ð804.Prakash,U.B.,Divertie,M.B.&Banks,P.M.(1979)Aggressivetherapyinacuterespiratoryfailurefromleukemicpulmonary,345Ð350.Primack,S.L.&Muller,N.L.(1994)High-resolutioncomputedtomographyinacutediffuselungdiseaseintheimmuno-compromisedpatient.RadiologyClinicsofNorthAmericaResnick,M.E.,Berkowitz,R.D.&Rodnan,T.(1961)DiffuseinterstitialleukemicinfiltrationofthelungsproducingthealveolarÐcapillaryblocksyndrome.AmericanJournalofMedicine,149Ð153.Rosenow,III,E.C.Wilson,W.R.Cockerill,III,F.R.(1985)Pul-monarydiseaseinimmunocompromisedhost(firstoftwopart).MayoClinicProcedure,473Ð487.Webb,W.R.,Stein,M.G.,Finkbeiner,W.E.,Im,J.G.,Lynch,D.&Gamsu,G.(1988)Normalanddiseasedisolatedlungs:high-resolutionCT.,81Ð87.Weibel,E.R.(1979)Lookingintothelung:whatcanittellus?AmericanJournalofRadiology,1021Ð1031.Winer-Muram,H.T.,Arheart,K.L.,Jennings,S.G.,Rubin,S.A.,Kauffman,W.M.&Slobod,K.S.(1997)Pulmonarycomplicationsinchildrenwithhaematologicalmalignancies:accuracyofdiagnosiswithchestradiographyandCT.ShortReport2003BlackwellPublishingLtd,BritishJournalofHaematology:1058Ð1061 SHORTREPORTLeukaemicpulmonaryinÞltratesinadultacutemyeloidleukaemia:ahigh-resolutioncomputerizedtomographystudyLeonardoPotenza,MarioLuppi,MonicaMorselli,StefaniaTonelli,NicolaDApollo,LucaFacchini,