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Introduction <p>Acute promyelocytic leukemia (APML) is a distinct subtype of acute myeloid leukemia typically characterized by hemorrhagic complications due to coagulopathy. Thrombotic events as the initial presentation of APML are exceedingly rare. We report a rare case in which cerebral venous thrombosis (CVT) and pulmonary thromboembolism (PTE) were the initial manifestations of APML, highlighting an atypical clinical presentation and its successful management.</p> <p>Clinical Presentation</p> <p>A 35-year-old woman presented with a 1-month history of persistent headache and neck pain, followed by two weeks of hemoptysis, low-grade fever, fatigue, and anorexia. Laboratory investigations revealed leukopenia and circulating promyelocytes, with bone marrow aspiration showing &gt; 80% promyelocytes with Auer rods (confirmed by PML/RARA FISH positivity), contrast-enhanced chest CT revealing PTE in the right pulmonary artery/inferior vena cava with right lower lobe infarction, and brain MRI/MRV demonstrating acute-subacute CVT with chronic left transverse sinus thrombosis.</p> <p>She was diagnosed with low-risk APML complicated by PTE and CVT. Therapeutic management included anticoagulation (heparin bridged to warfarin) combined with ATRA and arsenic trioxide (ATO) induction therapy. This approach resulted in marked clinical and hematologic improvement, allowing for discharge with plans for consolidation therapy and outpatient follow-up, demonstrating the feasibility and efficacy of combined anticoagulation and APML-targeted therapy.</p> Conclusion <p>This case highlights three crucial lessons: (1) APML can present with thrombotic complications before typical hemorrhagic manifestations or diagnosis, requiring heightened clinical suspicion; (2) concurrent management of thrombosis and APML with anticoagulation plus ATRA/ATO is both feasible and effective; and (3) multidisciplinary collaboration is essential for optimal outcomes in such complex presentations, emphasizing the need to consider APML in the differential diagnosis of unexplained thrombotic events.</p>

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Dual Thrombotic Complications in Acute Promyelocytic Leukemia: A Case of Cerebral Venous Thrombosis and Pulmonary Embolism

  • 期刊论文

  • 发表日期：

    2025年12月16日

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  • Yadelew Jember Kassie,
  • Temesgen Assefa Ayele,
  • Mustejib Abdla Hussen,
  • Yared Gebremicheal Tarekegn,
  • Demamu Agegn Adugna,
  • Bereket Bizuneh Bekele

摘要

Introduction

Acute promyelocytic leukemia (APML) is a distinct subtype of acute myeloid leukemia typically characterized by hemorrhagic complications due to coagulopathy. Thrombotic events as the initial presentation of APML are exceedingly rare. We report a rare case in which cerebral venous thrombosis (CVT) and pulmonary thromboembolism (PTE) were the initial manifestations of APML, highlighting an atypical clinical presentation and its successful management.

Clinical Presentation

A 35-year-old woman presented with a 1-month history of persistent headache and neck pain, followed by two weeks of hemoptysis, low-grade fever, fatigue, and anorexia. Laboratory investigations revealed leukopenia and circulating promyelocytes, with bone marrow aspiration showing > 80% promyelocytes with Auer rods (confirmed by PML/RARA FISH positivity), contrast-enhanced chest CT revealing PTE in the right pulmonary artery/inferior vena cava with right lower lobe infarction, and brain MRI/MRV demonstrating acute-subacute CVT with chronic left transverse sinus thrombosis.

She was diagnosed with low-risk APML complicated by PTE and CVT. Therapeutic management included anticoagulation (heparin bridged to warfarin) combined with ATRA and arsenic trioxide (ATO) induction therapy. This approach resulted in marked clinical and hematologic improvement, allowing for discharge with plans for consolidation therapy and outpatient follow-up, demonstrating the feasibility and efficacy of combined anticoagulation and APML-targeted therapy.

Conclusion

This case highlights three crucial lessons: (1) APML can present with thrombotic complications before typical hemorrhagic manifestations or diagnosis, requiring heightened clinical suspicion; (2) concurrent management of thrombosis and APML with anticoagulation plus ATRA/ATO is both feasible and effective; and (3) multidisciplinary collaboration is essential for optimal outcomes in such complex presentations, emphasizing the need to consider APML in the differential diagnosis of unexplained thrombotic events.