A 29-year-old woman with newly diagnosed acute promyelocytic leukaemia started on all-trans retinoic acid presents on day 9 with fever, dyspnoea, hypoxia, and weight gain. Chest imaging shows bilateral interstitial infiltrates and she has pleural effusion. Blood cultures are negative. What is the most appropriate management?

• A Discontinue ATRA permanently and switch to chemotherapy
• B Start empirical antifungal therapy and continue ATRA unchanged
• C Start intravenous dexamethasone and continue ATRA ✓
• D Give intravenous furosemide alone and observe

Explanation

This is differentiation syndrome, caused by cytokine release from maturing promyelocytes after ATRA (or arsenic trioxide) exposure, presenting with fever, respiratory distress, pulmonary infiltrates, effusions, and capillary leak. The standard treatment is immediate dexamethasone 10 mg twice daily, and ATRA is generally continued unless the syndrome is life threatening. Stopping ATRA permanently (option A) risks relapse, since differentiation syndrome is managed medically rather than by abandoning the curative agent.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.