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A-74-Year-Old-Man-Presenting-With-Cough,-Malaise,-
A-74-Year-Old-Man-Presenting-With-Cough,-Malaise,-
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A 74-year-old male farmer with a history of hypertension, hyperlipidemia, coronary artery bypass graft surgery, and an ex-smoker was admitted with symptoms of cough, malaise, fatigue, and shortness of breath lasting three weeks. On physical examination, he appeared distressed and had bibasilar inspiratory crackles and peripheral edema. Laboratory tests showed a high white blood cell count with monocytic dominance and low hemoglobin and platelet levels. Imaging revealed interstitial lung changes, mediastinal lymphadenopathy, bilateral pleural effusions, and alveolar ground glass opacities. Elevated N-terminal pro-brain natriuretic peptide and echocardiogram suggested moderate mitral regurgitation and raised suspicion of decompensated congestive heart failure.<br /><br />Diagnostic procedures confirmed acute myeloid leukemia (AML) with normal cytogenetic studies, while mediastinal lymph nodes showed leukemic infiltration. Treatment involved diuretics, antibiotics for potential infections, and chemotherapy with decitabine. The patient’s symptoms improved significantly, though mediastinal lymphadenopathy persisted. Bronchoscopy and biopsies confirmed extramedullary infiltration by leukemic cells.<br /><br />Discussion highlighted that extramedullary infiltration (EMI) in AML, particularly affecting the mediastinal lymph nodes, is uncommon and often presents with a poorer prognosis. This condition can mimic other malignancies and infections, making diagnosis challenging. EMI is more associated with myelomonoblastic subtypes of AML and high white blood cell counts. While no randomized controlled treatment trials exist due to its rarity, induction chemotherapy similar to AML treatment is recommended. The patient received chemotherapy, achieving complete remission, and evaluation for an allogeneic hematopoietic cell transplant was planned.<br /><br />The report underscores the need for comprehensive diagnostic studies, including fine-needle aspiration and additional molecular and cytogenetic assessments, to differentiate EMI and guide treatment in similar cases.
Keywords
acute myeloid leukemia
extramedullary infiltration
mediastinal lymphadenopathy
chemotherapy
AML
myelomonoblastic subtype
congestive heart failure
diagnostic procedures
hematopoietic cell transplant
leukemic infiltration
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