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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Treatment with all-trans-retinoic acid &#40;ATRA&#41; induces myeloid differentiation among leukemia cells in acute promyelocytic leukemia &#40;APL&#41;&#46; The differentiation syndrome &#40;DS&#41; or ATRA syndrome occurs in up to 25&#37; of APL patients treated with ATRA&#44; due to an inflammatory reaction accompanied by an increase in capillary permeability&#46; It is characterized by breathing difficulties&#44; fever&#44; pulmonary infiltrates&#44; pleuro-pericardial effusion&#44; kidney failure&#44; and hypotension&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 45-year-old man with a diagnosis of APL&#44; under treatment with ATRA &#40;45<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span>&#41; and idarubicin &#40;12<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; who developed fever and dyspnea hours after suspending prophylactic treatment with intravenous dexamethasone&#46; Pulmonary auscultation revealed bilateral crackles&#46; Chest radiograph showed a suspicious increase in density in the right lower lobe&#46; The patient&#39;s situation was complicated by oxacillin-sensitive <span class="elsevierStyleItalic">Staphylococcus aureu</span>s bacteremia&#44; due to an infected catheter&#44; which was treated with piperacillin-tazobactam and vancomycin&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">As no clinical improvement was observed&#44; a chest computed axial tomography was requested&#44; showing bilateral nodules and ground glass densities&#44; mainly in the lower lobes&#46; An area of parenchymal consolidation and associated pleural effusion was identified in the left lower lobe &#40;LLL&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A and B&#41;&#46; Bronchoalveolar lavage was performed and microbiological cultures were negative&#46; Treatment was started with intravenous dexamethasone &#40;10<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; showing favorable progress and complete resolution of the bilateral pulmonary infiltrate in less than 48<span class="elsevierStyleHsp" style=""></span>h&#46; A diagnosis was given of DS due to ATRA treatment&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The introduction of ATRA in the treatment of APL has been one of the most significant advances in the management of hematological cancers&#46; APL is now the most curable form of adult myeloid leukemia&#44; with full remission persisting at 5 years and 70&#37;&#8211;80&#37; survival&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> However DS associated with ATRA administration is probably the most toxic adverse event&#46; The prophylactic use and length of administration of corticosteroids are controversial&#46; Our patient received prophylactic treatment with intravenous dexamethasone&#44; but even so&#44; developed the syndrome&#46; The latest PETHEMA protocol recommends prophylaxis in all patients receiving &#62;5&#215;10<span class="elsevierStyleSup">9</span><span class="elsevierStyleHsp" style=""></span>l<span class="elsevierStyleSup">&#8722;1</span> for 15 days&#46; DS mortality is currently low &#40;1&#37;&#41;&#44; due to early treatment with corticosteroids&#44; along with the concomitant use of chemotherapy in combination with ATRA&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">DS is a clinical diagnosis based on a group of signs and symptoms in APL patients receiving induction treatment with ATRA or arsenic trioxide&#46; Three or more of the following findings are sufficient for diagnosis and starting treatment with glucocorticoids&#44; if other causes have been previously ruled out&#58; fever&#44; weight gain&#44; respiratory distress&#44; pulmonary infiltrates&#44; pleural and&#47;or pericardial effusion and&#47;or renal failure&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment should be initiated with intravenous dexamethasone &#40;10<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41; as soon as the syndrome is suspected&#46; Corticosteroid treatment should continue until the syndrome has resolved&#44; followed by gradual dose tapering over the subsequent weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion&#44; DS is a relatively common serious complication in APL patients&#44; and the time of presentation varies widely&#46; Take-home messages&#58; &#40;1&#41; suspect DS in APL patients receiving ATRA and&#47;or arsenic trioxide&#59; &#40;2&#41; detect early signs of DS to confirm clinical diagnosis&#59; and &#40;3&#41; examine the patient&#39;s behavior for rapid detection and treatment of complications&#46;</p></span>"
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