Principal Director, Medical Oncology & Hemato-Oncology, Fortis Hospital, Bannerghatta Road, Bengaluru, India
Part 11 of 12 in Diagnosing Common Cancers & Blood Disorders
Acute Promyelocytic Leukaemia: A Bleeding Emergency Hiding in Plain Sight
August 28, 2026
A 32-year-old schoolteacher with one child came to Dr. Raizada's clinic with a short history: two weeks of easy bruising on her arms, purple patches on her skin, and bleeding gums when brushing her teeth, particularly in the mornings. She also described tiredness, fatigue, mild breathlessness she had noticed recently, and occasional headaches, with the fatigue worsening over the previous ten days.
A carefully negative history
What she did not have mattered as much as what she did. No epistaxis, no blood in the urine, no gastrointestinal bleeding, no fever, no recent infection. She had taken no pain medication, antiplatelet drugs, or anticoagulants. There was no family history of a bleeding disorder. She was a non-smoker, had never consumed alcohol, followed a vegetarian diet, and had no recent travel history. On examination she had pallor and appeared fatigued but was not febrile. Multiple ecchymotic patches were visible on her arms and lower limbs, along with gingival bleeding and a purpuric patch on her cheek. There was no lymphadenopathy and no hepatosplenomegaly. Vital signs showed only mild tachycardia.
Why cytopenias, not just a coagulation abnormality, pointed to leukaemia
During the session, several differentials were floated: leukaemia, immune idiopathic thrombocytopenic purpura, a primary platelet disorder, an abnormal coagulation profile, heparin-induced thrombocytopenia. Dr. Raizada's diagnostic logic hinged on one distinction: an isolated coagulation problem, such as haemophilia or von Willebrand disease, would show an elevated PTT or APTT without cytopenias. This patient had both, a coagulopathy and cytopenias together, which pointed away from an isolated clotting factor abnormality and toward something affecting bone marrow production directly.
Her complete blood count showed hemoglobin of 8.2, a white blood cell count of 2,800, and platelets of 22,000 on smear. PT, PTT and INR were all prolonged, with an INR around 2.5. Fibrinogen was low, consistent with disseminated intravascular coagulation, DIC, and D-dimer was markedly elevated. The peripheral smear showed the finding that settled the diagnosis: numerous promyelocytes with Auer rods, cells that are highly characteristic of acute myeloid leukaemia, and specifically of acute promyelocytic leukaemia, AML M3.
Why this diagnosis is a same-day emergency
Dr. Raizada was blunt about the stakes: a patient in this state can die within the first week, or even the first day, because of the combination of prolonged bleeding and clotting times, low fibrinogen, and markedly elevated D-dimer on top of an existing bleeding tendency. The risk is a bleed anywhere, the gastrointestinal tract or the brain, and either can be fatal quickly. This patient's diagnosis was AML M3 with DIC, and it was treated as a medical emergency requiring acute, same-day management.
Treatment starts before the confirmatory report comes back
The urgent management sequence Dr. Raizada described does not wait for a final pathology report. Cryoprecipitate and fresh frozen plasma are given to correct the low fibrinogen, and platelets are transfused and kept above 50,000, which she described as mandatory in APML given the bleeding risk. ATRA, all-trans retinoic acid, given as tablets, is started even before the diagnosis is formally confirmed, because delaying it risks losing the patient. The first 48 hours, and the first week overall, are the critical window: patients who survive that first week have a 95 percent chance of being cured, with very good long-term survival.
This patient was started on ATRA alongside fresh frozen plasma, cryoprecipitate and platelet support. Confirmation followed with a bone marrow examination and a molecular test, which identified the PML-RARA fusion characteristic of this leukaemia subtype.
The clinical takeaway
A short history of bruising and gum bleeding in an otherwise healthy young adult, especially with fatigue and no other explanation, warrants an immediate complete blood count. If cytopenias and a coagulopathy appear together, and a peripheral smear shows promyelocytes with Auer rods, Dr. Raizada's guidance is to treat it as acute promyelocytic leukaemia until proven otherwise, and to start ATRA without waiting for bone marrow or molecular confirmation.
This guide is based on a live Jivo Masterclass — Dr. Niti Raizada taught doctors across Africa on February 1, 2026.
FROM THE LIVE Q&A
Dr. Stefan
What further investigations are needed to assess disease extension before starting management of this cervical cancer case?
Dr. Niti Raizada
Once the diagnosis is confirmed by biopsy, a staging scan, often a PET scan, establishes the exact stage, including whether the bladder, rectum, parametrium or lymph nodes are involved. Fitness for treatment is then assessed with kidney function testing (GFR) and audiometry, since some chemotherapy agents can affect hearing. Weekly chemotherapy is then given alongside radiation, with the potential radiation side effects explained to the patient beforehand.
Frequently Asked Questions
Between MRI and CT scan, which is the better imaging modality for staging this cervical cancer case?▼
MRI of the pelvis is excellent for local pelvic structures, but the upper abdomen and chest still need to be assessed, which is better done on CT. The recommendation is CT of the thorax combined with CT of the abdomen and pelvis with contrast, or alternatively MRI of the abdomen and pelvis with contrast combined with a CT of the chest. The chest is generally better seen on CT, and the pelvis is generally better seen on MRI.
I am seeing a Stage III breast cancer patient currently on filgrastim 300 micrograms for 3 days. What further treatment plan would you initiate for this patient?▼
Treatment depends on the patient's oestrogen receptor, progesterone receptor and HER2 status, and on whether she is receiving neoadjuvant chemotherapy followed by surgery, or surgery followed by adjuvant chemotherapy. Filgrastim is supportive care only, a white blood cell growth factor given to prevent a drop in counts after chemotherapy; it is not the primary cancer treatment. Its use depends on which chemotherapy protocol is being followed, but the treatment plan for the cancer itself is a separate, biology-driven decision.
Can the HPV vaccine still be given to a patient who has already tested positive for HPV?▼
Yes. If a nine-valent vaccine is given and the patient is positive for one strain of HPV, the vaccine still confers protection against the remaining eight strains it covers.
Are there any specific concerns in monitoring chronic liver disease, for example the frequency of ultrasound and the skill set of the radiographer?▼
Ultrasound should be done once every 6 months for a chronic liver disease patient, along with alpha-fetoprotein testing every 6 months. The skill of the radiographer matters because ultrasound is a subjective, operator-dependent test. If there is any doubt on ultrasound, a triple-phase CT scan or a multiphasic MRI should be done immediately.
We had a case where a gentleman with no history of alcohol or hepatitis could not get preliminary triple-phase CT staging done. The plan was hepatectomy, but he developed a crisis from bile build-up and passed away during the consultation and visa process. How could such cases be managed by a local doctor with limited information?▼
The key is always the right diagnosis at the right time. Liver cancer carries a real risk of coagulopathy and bleeding, so any patient with chronic liver disease should have regular PT, PTT and INR testing. If there is any bleeding diathesis, it needs to be treated, including with vitamin K and blood products if needed. Chronic liver disease patients also commonly have low white cell counts and low platelets, so basic blood counts should be checked regularly alongside liver and kidney function tests.
What symptoms should prompt an urgent blood count in an otherwise healthy young adult?▼
A short history, days to weeks, of easy bruising, purple patches on the skin, and bleeding gums, particularly alongside fatigue and breathlessness, warrants an immediate complete blood count even in a patient with no prior medical history.
How does acute promyelocytic leukaemia differ from an isolated bleeding disorder?▼
An isolated coagulation problem, such as haemophilia or von Willebrand disease, shows an elevated PTT or APTT without cytopenias. Acute promyelocytic leukaemia presents with both a coagulopathy and cytopenias together, along with promyelocytes and Auer rods on a peripheral smear.
Why is treatment started before a bone marrow biopsy confirms the diagnosis?▼
The first 48 hours and the first week overall are the critical window in this disease. Starting ATRA before formal confirmation avoids losing the patient to bleeding complications while the bone marrow and molecular results are still pending.
What is the survival outlook for patients who make it through the first week of treatment?▼
Patients who survive the first week have roughly a 95 percent chance of being cured, with very good long-term survival, which is why the acute management in that first week is treated as the decisive factor in outcome.
What immediate blood product support does a patient in this kind of bleeding emergency need?▼
Cryoprecipitate and fresh frozen plasma are given to correct low fibrinogen, and platelets are transfused and kept above 50,000, a threshold considered mandatory given the bleeding risk in this condition.
In This Series: Diagnosing Common Cancers & Blood Disorders
- 1.Diagnosing Common Cancers and Blood Disorders
- 2.Breast Cancer in Young Women: Reading the Red Flags Beyond Age
- 3.Breast Cancer Screening: What to Do at 18, 30 and 40
- 4.When a Persistent Cough Isn't Tuberculosis: Diagnosing Lung Cancer
- 5.Colon Cancer, Lynch Syndrome and the Case for Cascade Testing
- 6.Ovarian Cancer: The Silent Killer and Its Diagnostic Trail
- 7.Cervical Cancer: From Diagnosis to Concurrent Chemoradiation
- 8.HPV Vaccination: Who Needs It and What It Prevents
- 9.Hepatocellular Carcinoma: Diagnosing Liver Cancer in Chronic Liver Disease
- 10.Oral Cancer: Recognizing a Non-Healing Ulcer Early
- 11.Acute Promyelocytic Leukaemia: A Bleeding Emergency Hiding in Plain Sight
- 12.The Basic Blood Panel: A GP's First Line of Defence Against Missed Cancers