Abstract
A 44 year-old man was refered to the ICU for his sudden and severe dyspnea. His physical findings, chest radiograph, and ECG suggested acute pulmonary thromboembolism. Although his trachea was intubated due to severe hypoxemia and rapidly progressing conscious disturbance, it did not improved hypoxemia and, worse than that, induced sudden hypotention and pulmonary arterial congestion. None of medical treatments like inotropes including epinephrine, fluid administration, and mechanical ventilation did not improve his condition and we started emergent percutaneous cardiopulmonary support system (PCPS) to prevent circulatory collapse and probable death. PCPS raised his systolic blood pressure from 70mmHg to 100mmHg. We found hepatosplenomegaly after the beginning of PCPS by palpating his distended abdomen. Emergent pulmonary angiography showed multiple filling defects in the distal pulmonary arteries. Continuous hemodiafiltration (CHDF) was carried out for acute renal failure presenting anuria, hyperkalemia, and metabolic acidosis. Subsequent laboratory findings suggested acute crisis of chronic myelogenic leukemia as his background and we considered that pulmonary thromboembolism had resulted from hyperleukocytosis and hyperthrombocytosis. PCPS was discontinued six hours after the initiation because of gradual occlusion of artificial lung membrane and finally the patient lost his life. Autopsy revealed extensive infiltration of chronic myelocytic leukemic cells in major organs including both lungs. The final diagnosis is pulmonary thromboembolism by blastic crisis of chronic myelocytic leukemia and it is retrospectively non-indicative for PCPS. This case highlights the clinical, radiographic and histolic features of pulmonary leukostasis and reminds us that it is difficult to exclude fatal malignant diseases during resuscitation.
