Azoulay Elie, Fieux Fabienne, Moreau Delphine, Thiery Guillaume, Rousselot Philippe, Parrot Antoine, Le Gall Jean-Roger, Dombret Hervé, Schlemmer Benoît
Medical Intensive Care Unit, Hematology Department, Saint-Louis Teaching Hospital, Paris 7 University, France.
Am J Respir Crit Care Med. 2003 May 15;167(10):1329-33. doi: 10.1164/rccm.200206-554OC. Epub 2003 Feb 5.
Acute respiratory failure revealing acute monocytic leukemia is rare. We report 20 patients admitted to the intensive care unit (ICU) with three remarkable features: (1) rapidly progressive respiratory distress revealing acute leukemia, (2) monocytic leukemia, and (3) respiratory status deterioration after chemotherapy initiation. The median age was 50 years (17-72 years), and respiratory symptoms started 2 days (0-15 days) before ICU admission. The median leukocyte count was 98,250/mm3 (800-529,000), with circulating monocytic cells in all of the patients but one. Bone marrow examination was diagnostic of monocytic leukemia in all patients. At presentation, respiratory rate was 33 (18-50) per minute, and PaO2 on room air was 44.5 mm Hg (30-60). Chest radiographs revealed unilateral alveolar infiltrates (n = 1), bilateral alveolar infiltrates with (n = 3) or without (n = 11) pleural effusion, or diffuse interstitial infiltrates (n = 5). Alveolar hemorrhage was the main bronchoalveolar lavage finding, with monocytic cells retrieved from four patients. Respiratory function deteriorated after cancer chemotherapy initiation in all patients. Of the 15 patients who required mechanical ventilation, 10 died. Leukemic pulmonary infiltration as the first manifestation of acute monocytic leukemia should be recognized, and intensive management should be provided in anticipation of the respiratory function deterioration seen consistently after chemotherapy initiation.
以急性呼吸衰竭为首发表现的急性单核细胞白血病较为罕见。我们报告了20例入住重症监护病房（ICU）的患者，他们有三个显著特征：（1）以急性白血病为首发表现的快速进展性呼吸窘迫；（2）单核细胞白血病；（3）化疗开始后呼吸状况恶化。中位年龄为50岁（17 - 72岁），呼吸症状在入住ICU前2天（0 - 15天）开始出现。中位白细胞计数为98,250/mm³（800 - 529,000），除1例患者外所有患者均有循环单核细胞。所有患者骨髓检查均诊断为单核细胞白血病。就诊时，呼吸频率为每分钟33次（18 - 50次），室内空气中的动脉血氧分压（PaO₂）为44.5 mmHg（30 - 60）。胸部X线片显示单侧肺泡浸润（n = 1）、双侧肺泡浸润伴（n = 3）或不伴（n = 11）胸腔积液，或弥漫性间质浸润（n = 5）。肺泡出血是支气管肺泡灌洗的主要发现，4例患者灌洗回收的细胞中有单核细胞。所有患者化疗开始后呼吸功能均恶化。在15例需要机械通气的患者中，10例死亡。应认识到白血病肺浸润作为急性单核细胞白血病的首发表现，并应在预期化疗开始后持续出现的呼吸功能恶化时提供强化治疗。
