Warfarin resistance induced by teicoplanin.

Central nervous system (CNS) infiltration in a case of promyelocytic leukemia Sir, CNS infiltration is occasionally seen in acute myelogenous leukemia (AML); it is usually associated with those cases that present a monocytic component. Some investigators propose cranial irradiation for all AML patients not undergoing bone marrow transplantation, in order to prevent recurrence of the initial disease. 1 We describe a case of acute promyelocytic leukemia (APL) in which a patient had a relapse in the CNS. A 40-year-old male patient was admitted in April 1995, presenting hemorrhagic disorders. The coagulation screen demonstrated disseminated intravascular coagulation. Total blood counts showed: Hb 10.6 g/dL, platelets 22x10 9 /L and WBC 33 x10 9 /L (80% abnormal promyelocytes). The bone marrow was hypercellular with 95% anaplastic promyelocytes, myeloperoxi-dase and Sudan Black B positive. PAS and nonspecific esteras-es were negative. The immunophenotype on BM revealed CD13, CD33 and CD9 positive and HLA-DR, CD34, CD14, CD15, CD4, CD3, Tdt and CD61negative. Molecular study demonstrated PML/RAR-alpha rearrangement by RT-PCR analysis. An APL diagnosis was made and remission induction therapy consisting of ATRA (45 mg/m 2 /d)+ ARA-C (100 mg/m 2 /12h) and intensification protocol with daunorubicin and cytarabine (Ara-C) were administered. A complete morphological, cytogenetic and molecular remission was achieved in June 1995. In December 1995 he presented a BM relapse with the same clinical and biological features as the initial one. He was treated with ATRA followed by chemotherapy and achieved a complete remission in February 1996. One month later, headaches began and atypical promyelo-cytic cells were identified in the cerebrospinal fluid by morphology and cytochemical staining. The immunophenotype expressed CD13 (80%), CD33 (87%), CD9 (60%), showing absence of expression regarding HLA-DR and CD14. Blood film showed a leukoerythroblastic picture, with Hb 11 gr/dL, 222ϫ10 9 /L plts and WBC 8.8ϫ10 9 /L. Bone marrow smears showed a complete cytological remission but molecular studies determined the PML/RAR-␣ rearrangement in the bone marrow and in the cerebrospinal fluid. The diagnosis of CNS involvement was made, and the patient was treated with intrathecal methothrexate + ARA-C, followed by allogenic BM transplantation. A sustained hema-tological improvement was observed but he had a BM relapse three months later. There was no response to treatment and the patient died five months after transplantation. CNS involvement is an unusual form of relapse in APL and should be considerd a very serious symptom. 2,3 Neurological manifestations of acute myelogenous leukemia are …