Arsenic trioxide (ATO) has been successfully used as a treatment for acute promyelocytic leukemia (APL) for more than a decade. Here we report a patient with APL who developed a mitochondrial myopathy after treatment with ATO. Three months after ATO therapy withdrawal, the patient was unable to walk without assistance and skeletal muscle studies showed a myopathy with abundant cytoplasmic lipid droplets, decreased activities of the mitochondrial respiratory chain complexes, multiple mitochondrial DNA (mtDNA) deletions, and increased muscle arsenic content. Six months after ATO treatment was interrupted, the patient recovered normal strength, lipid droplets had decreased in size and number, respiratory chain complex activities were partially restored, but multiple mtDNA deletions and increased muscle arsenic content persisted. ATO
IntroductionArsenic trioxide (ATO) has a proven therapeutic efficacy in acute promyelocytic leukemia (APL). [1][2][3][4] In addition, the use of ATO is an appealing option in patients with APL because of its mild long-term toxicity profile compared with chemotherapy, especially with respect to myelosuppression and late complications associated with the use of anthracyclines. 3 However, arsenic is also an environmental carcinogen, with chronic exposure inducing liver injury, peripheral neuropathy, and increased incidence of cancer of the lung, skin, bladder, and liver. 5,6 In mammal cells, arsenic genotoxicity is mainly mediated by mitochondrial damage, including mitochondrial oxidative dysfunction. 7,8 Here we report a patient with APL who developed a delayed, severe, and partially reversible mitochondrial myopathy after being treated with ATO.
Case reportA 65-year-old female patient developed fatigue, shortness of breath, and thrombocytopenia. Morphologic examination of bone marrow biopsy demonstrated an abnormal accumulation of promyelocytes, and PCR of bone marrow and peripheral blood cells demonstrated the t(15;17)(q22;q12) translocation and the promyelocytic leukemia/retinoic acid receptor-␣ (PML/RAR␣) fusion gene on chromosome 15. She was diagnosed with APL and treated with all-trans retinoic acid (ATRA), 90 mg/day, for a month. Monitoring for APL relapse using a quantitative PCR test for the PML/RAR␣ t(15;17) transcript was positive, and she was then treated for 4 weeks with ATO, 65 mg weekly, with a total dose of 260 mg. She progressively developed diffuse muscle pain and weakness of all limbs, and ATO treatment was interrupted. In the following 3 months, muscle pain and weakness progressively worsened, and she was admitted with severe weakness of all limbs. Motor examination revealed weakness of proximal upper limbs (grade 4/5 on the Medical Research Council scale) and proximal lower limbs (MRC 2/5), and the patient was unable to walk without assistance. EMG examination showed myopathic changes, and serum creatine kinase levels were mildly increased (220 U/L, N Ͻ 200). Absolute neutrophil count, liver enzyme serum levels, and liver, renal, and thyroid functions were normal, ...