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Treatment of Acute Myeloid Leukemia M3 in a Patient with Crohn's Disease

A 49-year-old man diagnosed with Crohn’s disease at age 26, subsequently requiring multiple small bowel resections and colostomy, presented with a 2-week history of fevers, chills, and night sweats. A small bowel xray showed only 3-4 feet of remaining small bowel with diffuse Crohn’s disease involvement of this portion. Abdominal computed tomography showed loops of thickened small bowel but no fluid collection. Fat malabsorption was confirmed by serum carotene level of 23 pg/dl (normal, 48-200); a prothrombin time of 1.6, which normalized with intramuscular vitamin K; and a low 25-hydroxy-vitamin D (1 3 ng/ml; normal, 1442 ng/ml). Complete blood count (CBC) on admission showed pancytopenia (hemoglobin, 11 .O g/dl; white cell count, 600/mm3; platelets, 33,000/mm3 ). CBC 2 months before admission had been normal. Bone marrow biopsy revealed acute myeloid leukemia (AML), M3 subtype (acute promyelocytic leukemia), confirmed on cytogenetic studies. The patient was commenced on all-transretinoic acid (ATRA) chemotherapy, 40 mg orally twice a day. ATRA, a retinoid derived from naturally occurring vitamin Al, is highly effective in producing remission in patients with acute promyelocytic leukemia (1). The major mechanism of action of ATRA is to effect maturation of leukemic promyelocytes (2,3). After administration of ATRA, the pattern of blood counts changed (Table 1). Within the next few days, the patient had cleared undifferentiated blasts and promyelocytes from his circulation. The rapid drop in undifferentiated blasts and progranulocytes in the setting of an increasing neutrophil count indicates a convincing response to ATRA despite presence of only 3 to 4 feet of diffusely diseased small Table I