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case_images: Molecular biology clearance.
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case_images: During the gilteritinib therapy with a reduced dose, the patient experienced a progressive clinical improvement and was transfusion-free; the neutrophils count progressive recovered according to the progressive reduction blasts count, as well as quantitative PCR for FLT3-ITD and NPM1B mutation on bone marrow with consensual near complete chimerism recovery (Figure 1).
case_images: Haematological recovery.
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case_images: After 3.5 months of gilteritinib therapy (October 2020), the patient was in good clinical condition, neutropenia was solved (neutrophils 3700/microL) and noteworthy she achieved the second haematological complete remission with minimal molecular disease positivity for FLT3-ITD e NPM1B mutation and a near complete chimerism (Figure 2).
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case_images: Consolidating pneumonia before starting gilteritinib.
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case_images: The patient was therefore a candidate for gilteritinib monotherapy, but she developed hypotension, fever and bilateral consolidating pneumonia (Figure 3) with respiratory failure prior to start the drug.
case_images: Evolution of the skin rash during the differentiation syndrome (A-F).
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case_images: After 7 days of gilteritinib treatment, the patient developed a severe differentiation syndrome, with a rapidly progressing non-itchy maculo-papular skin rash (Figure 4A and B) associated with fever, weight gain and increase of transaminase values. A steroid therapy with dexamethasone 10 mg bid was initiated without discontinuing gilteritinib therapy, resulting in a gradual resolution of the skin rash (Figure 4C-F).
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case_images: CT scans of submandibular and laterocervical sarcoma.
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case_images: Despite an initial cytoreductive treatment with hydroxycarbamide, he developed a rapid and massive progression of submandibular and laterocervical sarcoma resulting in rapidly progressive inspiratory dyspnea and dysphagia (Figure 5).
case_images: Evolution of the cutaneous sarcoma in a submandibular abscess.
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case_images: The treatment was complicated by the evolution of cutaneous sarcoma in a submandibular abscess (Figure 6) caused by methicillin-sensitive Staphylococcus aureus; oral midostaurin was not initiated due to severe dysphagia.
case_images: Evolution of the myeloid sarcoma during the treatment with gilteritinib.
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case_images: After 6 months from the start of gilteritinib therapy, the patient was still alive with full recovery of performance status and complete regression of the sarcomatous lesions (Figure 7).
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case_images: NPM1/FLT3-ITD assays.
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case_images: AR mutations (Figure 8). No acute graft versus host disease were observed after transplant and the chimerism detected on day 30 on peripheral blood and bone marrow aspirate was of full-donor origin. After the discharge (day + 32), the patient did not show hepatic, renal and cardiac toxicity.