A 46-year-old woman was diagnosed with Philadelphia chromosome-positive ALL with a complex karyotype in February 2021. She received imatinib 400 mg/day with induction combination chemotherapy (daunorubicin, cyclophosphamide, vincristine, and dexamethasone) and achieved complete remission. During subsequent consolidation chemotherapy (methotrexate, cytarabine, and cyclophosphamide), the imatinib dose was reduced to 300 mg/day because of drug-related skin rash and generalized edema. Unfortunately, she developed a molecular relapse detected by BCR-ABL RT-qPCR after 6 months of imatinib treatment. The TKI was changed to dasatinib (140 mg/day).
One week after the start of dasatinib therapy, she developed CTCAE grade 2 fever (39.1 C) and dry cough. At the time of symptom onset, the respiratory rate was 24 breaths per minute and oxygen saturation in room air was 89.0%. The laboratory findings on admission were as follows: WBC count, 13.41 x 103/microl with 59.0% neutrophils; CRP, 2.84 mg/dl; procalcitonin, 0.13 ng/ml; aspartate transferase, 47 IU/L; and alanine transferase, 71 IU/L. Chest CT revealed diffuse GGO and peribronchial ill-defined nodules in the bilateral upper lobes, with a small amount of bilateral pleural effusion (shown in Figure 1(e)). BAL fluid analysis showed a lymphocyte-dominant pattern, and no microorganisms were identified, including PCP, CMV, respiratory virus, tuberculosis, or fungus. Empirical antibiotics were stopped, and considering that the patient was planning an allogeneic stem cell transplantation the next month, steroids were used without delay. Prednisolone at a dose of 1 mg/kg was started, and the dose was tapered off for 3 weeks. She showed symptomatic improvement, and follow-up chest CT showed resolution of diffuse GGOs in both lungs (shown in Figure 1(f)). The patient underwent haploidentical allogeneic hematopoietic stem cell transplantation from his son without significant toxicity.