Hindawi Publishing Corporation Case Reports in Hematology Volume 2012, Article ID 670347, 4 pages doi:10.1155/2012/670347 Case Report Paradoxical Immune Reconstitution Syndrome Presenting as Acute Respiratory Distress Syndrome in a Leukemia Patient during Neutrophil Recovery Issam A. Alawin and Bernard M. Karnath Internal Medicine Department, The University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA Correspondence should be addressed to Issam A. Alawin, alqimmah@maktoob.com Received 19 February 2012; Accepted 11 April 2012 Academic Editors: G. Damaj, K. Kawauchi, and R. Lowenthal Copyright © 2012 I. A. Alawin and B. M. Karnath. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Immune reconstitution inﬂammatory syndrome (IRIS) in the setting of antiretroviral therapy is well described, but it is not as common in non-HIV patients; here, we present a case of immune reconstitution inﬂammatory syndrome presenting as acute respiratory distress syndrome in a leukemia patient who had neutropenic fever and septic shock after high-dose cytarabine. During neutropenia recovery, his chest X-ray showed progressive worsening despite being on adequate therapy, we started him on steroids which resulted in signiﬁcant clinical improvement. 1. Clinical Vignette A 42-year-old male with acute myeloblastic leukemia (FAB classiﬁcation AML M2, WHO classiﬁcation: AML with recurrent genetic abnormalities: t (8 : 21)) received induction chemotherapy with cytarabine and idarubicin twice (he did not achieve remission with the ﬁrst induction) followed by consolidation with high-dose cytarabine. He received three cycles of high-dose cytarabine without incident. He was admitted to receive his fourth cycle and did well until fourteen days after chemotherapy when he developed neu- tropenic fever. His maximum temperature was 40.1◦C, his total white blood cell count was less than 100 cells/µL, blood cultures were drawn, and a chest X-ray was done (Figure 1). He was started on piperacillin/tazobactam and vancomycin. The next day, the two blood culture sets grew Gram-positive cocci in chains which were identiﬁed later to be streptococcus viridans. The same day, he became hypotensive and hypoxic (he required 100% FiO2 by nonrebreathing mask to maintain SpO2 above 95%), he was transferred to the intensive care unit for septic shock and acute hypoxic respiratory failure, and he required vasopressors and intubation for mechanical ventilation. Patient was started on caspofungin. Over the following three days, he continued to have low- grade fever but overall the temperature was trending down and his oxygen requirement represented by FiO2 and positive end expiratory pressure (PEEP) were weaned down. We did a bronchoscopy looking for a cause of infection and hypoxia, bronchoalveolar lavage (BAL) grew respiratory ﬂora, and there was no evidence of aspergillus. Eighteen days after chemotherapy, the day of recov- ery of neutropenia, his CXR showed signiﬁcant worsen- ing with bilateral inﬁltrates (Figure 2), his fever trended up, and his mechanical ventilation settings (FiO2 and PEEP) increased, he developed acute respiratory distress syndrome (his PaO2/FiO2 was less than 200 with bilateral inﬁltrates on CXR). Over the following three days, he continued to deteri- orate clinically and CXR was getting worse (Figure 3) despite being on appropriate antibiotics and without an evidence of a new infection. Granulocyte colony-stimulating factor (GCSF) was discontinued when the absolute neutrophilic count reached 8000 cell/µL. A transthoracic echocardiogram did not show an evidence of heart failure or valvular vegeta- tion. Three days after his neutrophil recovery, we concluded that his deterioration must be attributed to the recovering