We present the case of a 42-year-old female patient with no significant pathological history. She presented at the Department of Emergency Ophthalmology, claiming a drop of vision in the left eye (LE), which gradually installed during the last 48 hours before she presented at the Emergency Department. There was no history of ocular trauma or surgery.
The ophthalmic evaluation at the time of admission revealed a well-contoured and normally colored optic disc, retinal hemorrhage radiating from the inferotemporal optic disc margin with a flame shaped aspect, dot-spot retinal hemorrhages and low foveolar reflex, at the right eye (RE). At the left eye (LE), an elevated optic disc with moderate retinal oedema marked retinal hemorrhages, and preretinal hemorrhage with no foveolar reflex. The slit lamp examination of the anterior segment was normal for the RE and delayed RFM for the LE.
The visual acuity (VA) for the RE was 0.9 with correction and for the LE was counting fingers at 1 meter, not correctable.
In the first stage of biohumoral status assessment, we performed blood tests such as CBC, erythrocyte sedimentation rate, C-reactive protein, fibrinogen, blood glucose test, lipid profile, total serum protein and thyroid markers. The results of blood test showed a severe pancytopenia with 1.43 X 103/ microl leukocytes, 24 X 103/ microl thrombocytes and severe low levels of Hb 5 g/ dl, inflammatory markers were high, erythrocyte sedimentation rate ESR 60 mm/ h, CPR 17.63 mg/ l, lower fibrinogen levels 94.77 mg/ dl. Given the analyses, we suspected disseminated intravascular coagulation and we performed D- Dimeri test with positive result.
Interdisciplinary medical evaluations were made by colleagues from internal medicine, cardiology and hematology departments. In the multidisciplinary team, we decided to complete the investigations with Hemostasis Analyzer Markers (Pts, Ptr, INR, and APTT), which suggested a hemostasis disorder. Lactate dehydrogenase test, Polymerase chain reaction (PCR) and ferritin were on high levels, serum iron was on low levels, negative serology for HIV, Hepatitis B and Hepatitis C, anti-thyroid peroxidase antibodies (anti-TPO antibodies) and the thyroid hormones within normal limits. At the time of admission, the CT for head segment did not indicate pathological changes.
A bone marrow aspiration and biopsy were made. Leukocyte concentrate, cytological blood smear test, and the cytological examination of the spinal cord were inconclusive because they showed a low percentage of promyelocytes of approximately 8% and blasts of approximately 6%. Due to the patient's general condition changing with the onset of fever we decided to transfer her to the intensive care unit. Given the unfavorable evolution, we repeated the CT for head segment, which showed multiple supratentorial lesional processes predominantly in the white matter and calf body and a few isolated thalamic lesions that raised the suspicion of brain microabscesses in a septic context (Fig. 1). The head CT also revealed a modulation of signal diffusion in the left eye-viewable on the hemosiderin-susceptible sequence in moderate hyposignal, which almost totally interests the vitreous body, possibly hemorrhagic.
At the CT for thorax and abdomen, we found multiple pulmonary outbreaks spread in both lungs, parapneumonic pleurisy of 6 mm on the right and 5 mm on the left, pelvic ascites fluid with infiltrative appearance around the genitals. Blood culture test was negative; RT-PCR Sepsis test was negative for S. aureus, Enterococcus faecalis, Streptococcus agalactiae, Enterobacteriaceae, Candida spp and Pseudomonas aeruginosa. 
The examination of the posterior pole revealed marked changes of the retina and optic disc with massive hemorrhages that practically covered a large part of the posterior pole for the LE and for the RE extensive retinal hemorrhage, marked papillary edema, both eyes with vitreous condensation (Fig. 2,3). It was difficult to determine the patient's VA given the general altered status.
The patient was transferred to the hematology department having an extended mucosal cutaneous hemorrhage syndrome (Fig. 4), hepatic cytolysis syndrome and started the specific treatment for LAM3 with Vesanoid 45 mg/ m2 - 80 mg/ day. The general status of the patient worsened, becoming confused, jaundice with haematological status in the collapse with WBC=55.76 X 103/ microl, Neutrophils 0.00 X 103/ microl, Lymphocytes 0.00 X 103/ microl, Monocytes 0.00 X 103/ microl, Eosinophils 0.00 X 103/ microl, Basophils 0.02 X 103/ microl, she had PLT=8 X 103/ microl, Hb=7.7 g/ dl.
In the hematology department, the test battery was extended with flow cytometer, PML RAR alpha transcript t 15, 17, and immunohistochemistry. The result of PML RAR alpha screening transcript (15;17) was positive.
The patient received antibiotics, red blood cell transfusion, freshly frozen plasma platelets, cryoprecipitate, corticosteroid, and haemostatic. Due to severe coagulopathy and severe fibrinogenemia, she received treatment with Haemocomplettan fibrinogen concentrate.
Thirteen days after admission, the patient suffered a respiratory cardiac arrest and died. Later on, after the patient died, the result of Bone Marrow Biopsy revealed a hypercellularity with intertrabecular infiltration of blastic cells with cytoplasmic granulations and Auer rods, about 80-90% of the total cells.