Spontaneous Complete Remission Of Acute Myeloid Leukemia In The Absence Of Disease-modifying Therapy Following Severe Pulmonary Involvement By Coronavirus Infectious Disease-19
Barkhordar, M., Rostami, F. T., Yaghmaie, M., Abbaszadeh, M., Chahardouli, B., & Mousavi, S. A. (2022). Spontaneous Complete Remission of Acute Myeloid Leukemia in the Absence of Disease-Modifying Therapy following Severe Pulmonary Involvement by Coronavirus Infectious Disease-19. Case reports in hematology, 2022, 2603607. https://doi.org/10.1155/2022/2603607
View Original Source →Abstract
Coronavirus infectious disease-19 (COVID-19) usually alters the innate and adaptive immune setting by excessive production of proinflammatory cytokines, leading to a deviation in the natural course of simultaneous malignant disease. In the absence of disease-modifying therapy, complete remission of acute myeloid leukemia (AML) is an extraordinary event caused mainly by an immune-related mechanism secondary to a severe infectious process. We present a 57-year-old woman with a new diagnosis of AML associated with a 11q23/KMT2A abnormality who had achieved temporary spontaneous remission in the absence of disease-modifying therapy following the severe pulmonary infection with coronavirus lasting for six months. We review the literature and explain the potential impact of stimulated immune responses by COVID-19 on induction of remission in a patient with AML that could provide an excellent opportunity for new immune-based therapies to evolve for the hematologic malignancies. Despite the high ability of the immune process to destroy the malignant cells, the remission of duration is usually short. Therefore, it seems that continuing treatment after SR of AML by a consolidation regimen or bone marrow transplantation, based on a risk-adapted treatment approach, may reduce the recurrence risk.
Case Details
Disease Location
Bone marrow
Personal Characteristics
57-year-old woman
Clinical Characteristics
Presented with a petechial skin rash and bruising on the trunk and lower extremities, and fatigue for about two weeks. The initial workup revealed anemia, thrombocytopenia, and leukocytosis, and circulating blasts on the peripheral blood smear. Bone marrow aspiration/biopsy (bma/b) was performed and confirmed the initial diagnosis of acute myeloid leukemia (aml) m2. Pathologic evaluation revealed the 60% cellularity consisted of blast sheets occupying more than 65% of the bone marrow space with reduced megakaryocytes and scattered erythroid precursors. Chromosomal evaluation and flow cytometry findings confirmed the diagnosis of aml m2 with 11q23/kmt2a abnormality. During the first few days of hospitalization and before starting the induction chemotherapy, she developed fever (38 °c), shortness of breath, cough, and hypoxemia. Coarse crackles were heard on auscultation of the lung. She received empirical therapy with meropenem and azithromycin, followed by vancomycin and voriconazole for neutropenic fever. Pcr for sars-cov-2 was performed, which turned positive, and a repeated CT scan showed bilateral and multifocal (dominantly peripheral) patchy ground-glass opacities suggestive covid-19. She received respiratory support by niv (noninvasive ventilation), and was treated with remdesivir at 200mg intravenously (IV) on the first day, followed by 100 mg daily for five days and dexamethasone IV at 8 mg daily for ten days. She was transfused by six units of packed red blood cells and ten units of platelets. A chest CT scan was repeated 26 days after admission and showed notable progression in bilateral alveolar opacities with a coarse reticular pattern compared with the previous CT scan. Therefore, pirfenidone, colchicine (0.6 mg twice daily), and oxygen therapy with a reserve bag mask were prescribed. The disease recurred after 6 months of complete remission. Therefore, the patient received the induction chemotherapy with cytarabine and daunorubicin (7 + 3) regimen and achieved a morphologic remission at bma/b on day 28. In the second remission, she underwent allogeneic bone marrow transplantation from an HLA-matched sibling donor
Remission Characteristics
A new bone marrow aspiration was performed 2 months after admission, it revealed a normocellular marrow with 55% cellularity contained less than 5% blast and trilineage maturation and flow cytometry showed about 3% myeloblast having the expression of CD34 and CD117.
Treatment & Mechanisms
Proposed Remission Mechanisms
Immune-dependent mechanism secondary to the in- fectious process is considered the probable leading cause
Clinical Treatment
Bone marrow aspiration/biopsy, meropenem, azithromycin, vancomycin and voriconazole. Remdesivir, dexamethasone, red blood cells, platelets, pirfenidone, colchicine, oxygen. Cytarabine and daunorubicin, bone marrow transplantation (after remission and relapse)
Non-Clinical Treatment
None reported