Correct!
5. Fibrinolytic DIC secondary to acute promyelocytic leukemia (APL).
Leukostasis presents with prominent neurological complications that can include intracranial hemorrhage, but it is usually seen in patients with acute myelogenous leukemia and hyperleukocytosis exceeding 100 x103/uL, and it is not typically associated with coagulopathy. Hyperviscosity syndrome due to multiple myeloma or Waldenstrom macroglobulinemia causes obstruction of CNS vasculature leading to a variety of neurological complications including coma and stroke, due to alteration of the physical properties of blood rather than through coagulopathy. Thrombotic thrombocytopenia purpura (TTP) is associated with thrombocytopenia and CNS hemorrhage, but is typically also associated with fever, acute kidney injury, and microangiopathic hemolytic anemia with prominently apparent schistocytes. TTP does not typically perturb the INR or aPTT. Delayed heparin induced thrombocytopenia (HIT) (occurring after the typical 10-day window) related to his previous hospitalization, during which he likely received heparin, could explain thrombocytopenia and thrombotic stroke, but would not explain DIC or a bleeding diathesis. Fibrinolytic DIC secondary to APL best explains the patient’s clinical and laboratory presentation.
A presumptive diagnosis of acute promyelocytic leukemia (APL) with secondary fibrinolytic DIC was made. Flow cytometry and quantitative RAR/PML by real-time PCR testing were performed. A repeat manual differential of peripheral blood showed 52% “blasts,” some of which contained Auer rods.
Which of the following are true regarding APL with fibrinolytic DIC? (Click on the correct answer to be directed to the fifth of six pages)