A TACO PRESENTATION MIMICKING NEW DIAGNOSIS OF ACUTE MYELOID LEUKEMIA WITH TUMOR LYSIS

Abstract

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Transfusion-associated circulatory overload (TACO) should be suspected in patients who progress into acute respiratory distress and decompensate within several hours of a blood transfusion. TACO is separated from transfusion-related acute lung injury (TRALI) physiologically in development of hydrostatic cardiogenic edema rather than permeability edema. According to the NHSN (National Healthcare Safety Network) 2016-TACO clinical definition, the criteria consists of new onset dyspnea and cough, positive fluid balance, elevation in brain natriuretic peptide (BNP), and radiographic findings of pulmonary edema with evidence of left heart failure. Unfortunately, patients with leukemia, previous stem cell transplants, and other hematologic disorders can be more predisposed to TRALI; the risk factors are unclear although HLA incompatibility is theorized to be associated. Although TRALI has been mentioned in a few case reports for leukemia patients, interestingly TACO has not been described at all. CASE PRESENTATION: A 58-year-old male, otherwise healthy, initially presented with fatigue and shortness of breath. He was hemodynamically stable, and labs showed hemoglobin of 4.2 (normal 13.5—17.5), white blood cell count 20.1 (4.5—11.0), and platelet count 43 (160—420), BNP 617 (0—900 pg/ml). He received one unit of packed red blood cells and in several hours became hypoxic and tachypneic, hypertensive to 233/160, and required intubation. Repeat BNP was 1,676. Chest CT (Figure 1) showed bilateral pleural effusions and concern for ARDS. An echocardiogram showed new severely reduced systolic function with ejection fraction (EF) of 29% along with grade 2 diastolic dysfunction (Figure 2). Given flash pulmonary edema and a rising WBC count, he was given aggressive diuresis and broad spectrum antibiotics. WBC trended as high as 71.7, creatinine worsened to 2.0 (0.8—1.4 mg/dl), uric acid increased to 11.1 (3.7—7.0 mg/dl) and LDH worsened to 2,907 (87-241 units/L). Bone marrow biopsy showed hypercellular marrow with 21% blasts, trilineage dyspoiesis, consistent with acute myeloid leukemia with myelodysplasia related changes (AML-MRC) with positive CD117 stain. Patient was treated with rasburicase and allopurinol for tumor lysis. Repeat echo showed recovered EF to 55%, and patient was started on daunorubicin and cytarabine for chemotherapy. DISCUSSION: Signs of volume overload such as shortness of breath can occasionally be the clinical presentation of AML. Transfusion of packed RBCs was thought to contribute to acute cardiogenic pulmonary edema. This patient fulfilled all criteria of TACO surveillance diagnosis including acute respiratory distress within 6 hours of transfusion, pulmonary edema, volume overload, and BNP elevation. CONCLUSIONS: This case aims to remind the clinician to be cognizant of underlying etiologies that can "tip over” the threshold for TACO, such as leukemia. Reference #1: Semple JW, Rebetz J, Kapur R. Transfusion-associated circulatory overload and transfusion-related acute lung injury. Blood. 2019 Apr 25;133(17):1840-1853. doi:10.1182/blood-2018-10-860809. Epub 2019 Feb 26. Review. Reference #2: Ido, K., Aoyama, Y., Nagasaki, J., Koh, S., Ichihara, H., Harada, H., … Mugitani, A. (2017). Pulmonary Involvement of Acute Myeloid Leukemia Mimicking Transfusion-related Acute Lung Injury. Internal medicine (Tokyo, Japan), 56(18), 2493–2496. doi:10.2169/internalmedicine.8505-16 Reference #3: Kuriyan M. Commentary on TRALI in leukemia. J Pediatr Hematol Oncol. 2006 Jun;28(6):328-30. DISCLOSURES: No relevant relationships by Jonathan Chang, source=Web Response No relevant relationships by JENNIFER CHIURCO, source=Web Response No relevant relationships by Hanyuan Shi, source=Web Response No relevant relationships by Justin Spraglin, source=Web Response