[Pulmonary toxicity caused by drugs]

Neglected respiratory toxicity caused by cancer therapy

When a patient with lung cancer presents non-specific respiratory symptoms there are many diagnostic options. Chemotherapy is the cornerstone of treatment in many stages of lung cancer and its toxicity is well known. The main priority is to prevent life-threatening diseases such as lung infection, which can be treated successfully if a prompt, accurate diagnosis is given. Drug-induced pulmonary disease must be avoided at all costs but it is also important to avoid side-effects of drugs which do not directly interfere with respiratory physiology but may impair gas exchange. This review highlights the risks and characteristics of non-cytostatic-induced lung toxicity caused by agents that have been commonly used to treat cancer in recent decades. Physicians should be alert to the possibility of this neglected non-chemotherapy-induced lung toxicity in cancer patients, since early withdrawal of the offending drug is mandatory.

[Strong suspicion of lung toxicity due to riluzole]

Riluzole is a drug used in the treatment of amyotrophic lateral sclerosis. To date, reports of lung toxicity have been exceptional. We present the case of a 74-year-old man diagnosed with amyotrophic lateral sclerosis. Following 3, 5 months of treatment with riluzole (Rilutek), the patient began to present a clinical picture consisting of nonproductive cough, progressive dyspnea (even with slight exertion), weakness, and radiologic progression with the appearance of predominantly peripheral bilateral pulmonary infiltrates that did not respond to treatment with amoxicillin-clavulanic acid. Bacterial tests did not reveal the presence of germs, nor did other examinations suggest an alternative diagnosis. The patient did not resume treatment with the drug or undergo complementary procedures aimed at obtaining histologic samples. Nevertheless, the coincidence in time, lack of response to antibiotic treatment, remission of symptoms following withdrawal of the drug without initiating any other treatment except 40 mg/d of methylprednisolone for 6 days, absence of alternative diagnoses, and suggestive clinical and radiologic findings all together point to toxicity due to riluzole.

[Lung toxicity due to thalidomide]

Although the side effects of thalidomide are well known, lung toxicity has not been reported. We describe the case of a 65-year-old man with multiple myeloma (IgG kappa) in stage IA who, on the thirty-seventh day of treatment with thalidomide, developed acute coughing, general malaise, dyspnea at rest and sudoresis. Blood pressure was 90/60 mm Hg and temperature was normal. An interstitial and alveolar pattern was visible on the right side of a chest film and arterial blood gases indicated partial respiratory insufficiency (pH 7.40, PaCO2 40 mmHg, PaO2 47 mmHg). Blood analysis showed alterations expected for multiple myeloma and microbiology was negative (sputum and blood cultures and urinary antigen detection for Streptococcus pneumoniae and Legionella pneumophila). After thalidomide was withdrawn and oxygen and intravenous corticoids were administered, outcome was good. A chest film 4 days later was normal and arterial blood gases showed that respiratory insufficiency had disappeared. We conclude that severe lung toxicity should be included among the potential adverse effects of thalidomide.

Chemotherapy-induced pulmonary toxicity in lung cancer management

Chemotherapy is the cornerstone of therapy in many stages of lung cancer. Many diagnostic options have to be taken into account when a patient suffering from lung cancer presents with nonspecific, respiratory, clinical manifestations. A multidisciplinary diagnostic approach is then warranted. The top priority is to rule out those life-threatening causes, such as lung infection, that could be properly treated if a right diagnosis is early. To reach a definite diagnosis frequently requires that one or more diagnostic, pneumologic techniques are performed. Regarding to drug-induced pulmonary disease, prevention is mandatory. In this review we have tried to highlight the risk and characteristics of cytostatic-induced pulmonary toxicity caused by those agents that have been commonly employed to treat lung cancer for the last decades. When treating lung cancer patients, a high clinical suspicion of chemotherapy-induced lung toxicity should be kept in mind since an early withdrawal of the offending drug is the most efficacious therapy.