Two patients diagnosed as having acute promyelocytic leukemia (APL) and disseminated intravascular coagulation (DIC) were closely followed by serial fibrinolysis and coagulation studies from the day of admission until completion of the first course of chemotherapy. One patient was treated with intravenous heparin and Trasylol (Bayer AG, West Germany) and the other received heparin therapy without Trasylol. In Patient 1, hyperfibrinolytic activity, not observed during the administration of Trasylol, developed with its discontinuance. In Patient 2, hyperfibrinolysis was observed coincidentally with a decrease in APL cells due to chemotherapy. These results indicate that hyperfibrinolysis in APL is not associated with DIC. Deaths from intracerebral hemorrhage are frequently described, and account for a significant number of early deaths. Therapy with intravenous heparin has been attempted to control intravascular coagulation in APL patients, and recent reports suggest that it may be beneficial. Indeed, deaths due to intracerebral hemorrhage appeared to be less frequent in patients given However, the role of heparin in controlling the coagulopathy of APL remains controversial.In this article, we report on fibrinolysis which persisted in two patients with APL and DIC despite treatment with heparin. Our studies support the clinical impression that antifibrinolytic therapy may be the treatment of choice in addition to heparin therapy.
Case Reports
Case 1A 26-year-old woman was admitted with a 10-day history of anemia and subfebrile condition and was given a blood transfusion. On admission, there were symptoms of nausea and vomFrom the Departments of *Surgery and ?Internal Medicine, The Center for Adult Diseases, Osaka, Japan.Address for reprints: Shingi Imaoka, MD, Department of Surgery, The Center for Adult Diseases, Osaka 1-3-3 Nakamichi, Higashinariku, Osaka, Japan.Accepted for publication February 14, 1986. iting. Results of the physical examination were essentially normal. Her hemoglobin level was 9.3 g/dl, leucocyte count was 1800/mm3 with 55.8% promyelocytes, and platelet count was 79,000/mm3. A bone marrow aspiration showed acute promyelocytic leukemia; 57% promyelocytes/35,000 nucleic cells/mm3. She was diagnosed as having DIC on the basis of coagulation studies: 30% (21 seconds) prothrombin time (PT) (normal, 12 seconds), 40 seconds activated partial thromboplastin time (AFTT) (normal, 27-33 seconds), 80 mg/dl fibrinogen (Fbg), 98% antithrombin I11 (AT 111), 80 pg/ml fibrin/fibrinogen degradation products (FDP), 28.3 mm2 lysis area of fibrin plate, but a negative protamine sulfate test.The patient received heparin by constant infusion (400-800 U/hr), from the beginning of the treatment on the first hospital day (day I), and Trasylol (Bayer AG, West Germany) (500,000 U/day) intravenously (Fig. 1). Combination chemotherapy with daunomycin was begun on day 1, and predonisolone, cytosine arabinoside, and 6 mercaptopurine were added on day 9 and discontinued on day 13. Trasylol therapy was begun on day 1 and on...
