Patient No 02,048,211, male, 21 years old, 176 cm/67 kg, he went to the outpatient clinics due to intermittent fever for more than 2 months on Jan 30th 2020.
The patient had fever on Dec 1st, 2019, without chills or other symptoms, Tmax of 38.2  C. He went to the local hospital and received some Chinese traditional medicine to relieve symptoms, from then on patient had intermittent low-grade fever. On January 30, 2020, patient suffered from gingival bleeding, he carried out some laboratory tests in the local hospital. CBC: WBC 28.63 x 109/L, Hb 94 g/L, PLT 7 x 109/L. Coagulation analysis: PT 15.5 s, Fib 120 mg/dL, d-dimer 2614 ng/ml. Chest CT showed infection in the upper and middle lobe of the right lung; localized atelectasis in the lingual segment of the left upper lobe and possible infection; and localized atelectasis in the lower lobe of the left lung (Fig. 1). The patient was controlled as a suspected case in the isolation ward according to fever, multiple pulmonary patchy shadows and a history of direct contact with relatives in Wuhan, although COVID-19 PCR of throat swab was negative three times.
On Feb 1st 2020, the patient had dry tap bone marrow aspiration, and peripheral blood (PB) smear showed typical APL. The patient was treated with ATRA, Hu, allopurinol and sodium bicarbonate for leukemia and with imipenem for anti-infection and with adequate supportive transfusion of red blood cells, platelets, fibrinogen and prothrombin complex. On Feb 2nd 2020, patient complained about headache and dizziness. No abnormality was found on brain CT scan. CBC: WBC 25.95 x 109/L, Hb 62 g/L, PLT 8 x 109/L, and leukostasis was suspected and oral Vp-16 100 mg Qd (Brand name: Lastet; Manufacturer: kabuskiki kaisha Japan Co., Ltd) was taken to reduce tumor burden and dexamethasone 5 mg QD preventing DS. On Feb 10th 2020 coagulopathy was corrected completely. On Feb 12th 2020 PML-RARA (Bcr1 isoform) in peripheral blood was 80.0%, so APL (high-risk) was diagnosed. RIF 60 mg/kg/d were administrated. During the course of induction, patient suffered from intermittent fever, pulmonary infection and acute orchiepididymitis, so imipenem, vancomycin, oseltamivir and voriconazole were administrated for anti- infection. We monitored the complete blood count trend (Fig. 3-1). Hepatic function: ALT 21-72 U/L, AST 23-49 U/L, TBIL 12.1-14.7umol/L. On February 25th, 2020, the chest CT examination showed that both lung lesions returned to normal. On Mar 3rd, 2020, CBC: WBC 2.28 x 109/L, Hb 75 g/L, PLT 88 x 109/L, and peripheral blood smear showed no APL cells. On Mar 3rd, 2020, bone marrow aspiration showed no promyelocytes, PML-RARA quantification in bone marrow 8%. Lumbar puncture and intrathecal injection were performed to prevent central nervous system leukemia, routine biochemical test of cerebrospinal fluids showed no abnormality. The patient achieved hematological remission, and all other complications were cured. Case 1 patient was treated with VP16 750 mg and Hu 11 g in total, 35 days of ATRA (25 mg/m2/d) and 28 days of RIF (60 mg/kg/d), then morphological evaluation of bone marrow showed complete remission. The patient only suffered from grade 1 hepatic dysfunction, no renal dysfunction and no QTc prolongation. The coagulopathy was corrected completely on the 8th day after ATRA. CBC returned to normal on 45 days since the initial treatment. 34 g fibrinogen, 10 U red blood cells and 17 U platelets were infused in total.