Cyclophosphamide-induced acute respiratory distress syndrome

Drug-induced interstitial lung disease: a narrative review of a clinical conundrum

INTRODUCTION

Drug-induced interstitial lung disease (DI-ILD) is increasing in incidence, due to the use of many new drugs across a broad range of cancers and chronic inflammatory diseases. The presentation and onset of DI-ILD are variable even for the same drug across different individuals. Clinical suspicion is essential for identifying these conditions, with timely drug cessation an important determinant of outcomes.

AREAS COVERED

This review provides a comprehensive and up-to-date summary of epidemiology, risk factors, pathogenesis, diagnosis, treatment, and prognosis of DI-ILD. Relevant research articles from PubMed and Medline searches up to September 2023 were screened and summarized. Specific drugs including immune checkpoint inhibitors, CAR-T cell therapy, methotrexate, and amiodarone are discussed in detail. The potential role of pharmacogenomic profiling for lung toxicity risk is considered.

EXPERT OPINION

DI-ILD is likely to be an increasingly important contributor to respiratory disability in the community. These conditions can negatively impact quality of life and patient longevity, due to associated respiratory compromise as well as cessation of evidence-based therapy for the underlying disease. This clinical conundrum is relevant to all areas of medicine, necessitating increased understanding and greater vigilance for drug-related lung toxicity.

Rapid-onset acute respiratory distress syndrome after mastectomy in a breast cancer patient: A case report and review of literature

RATIONALE

Postoperative acute respiratory distress syndrome (ARDS) often results in severe morbidity and mortality in surgical patients. The etiology of this condition is complex, especially in cancer patients.

PATIENT CONCERNS

We encountered a 53-year-old woman with left breast cancer, cT1cN2M0, stage IIIA with left axillary lymph node metastasis. She had received chemotherapy with 4 cycles of doxorubicin plus cyclophosphamide, and 4 cycles of trastuzumab plus docetaxel within a span of 6 months. Subsequently, she underwent left simple mastectomy and axillary lymph node dissection, shortly after which she developed respiratory distress with progressive desaturation and hemoptysis.

DIAGNOSIS

ARDS was diagnosed using the Berlin criteria. Her arterial blood gas analysis revealed profound hypoxemia and her chest imaging was suggestive of pulmonary edema. She developed diffuse alveolar hemorrhage (DAH) that was confirmed with bronchoscopy and hemorrhagic samples on bronchoalveolar lavage.

INTERVENTIONS

She was mechanically ventilated with lung protective measures for management of ARDS. In addition to antibiotic cover with amoxicillin sodium-potassium clavulanate for occult infections during her stay in the intensive care unit, we administered epinephrine inhalations, intravenous treatment with tranexamic acid, and methylprednisolone for DAH.

OUTCOMES

Her clinical course improved; she was extubated successfully on day 7 and discharged home on day 11.

LESSONS SUBSECTIONS

Chemotherapeutic agents may cause pulmonary toxicity through a direct cytotoxic effect or immune-mediated reactions and result in an increased risk of development of ARDS. Furthermore, surgery may trigger a systemic inflammatory response syndrome that can also induce ARDS. In our patient, the development of ARDS was attributed to the combined effects of surgery and chemotherapeutic agents (trastuzumab or docetaxel). When patients undergo major surgery after receiving chemotherapeutic agents, careful consideration is necessary to prevent the development of ARDS.

Fatal Interstitial Pneumonitis Rapidly Developed after the First Cycle of CHOP with Etoposide Combination Chemotherapy in a Patient with Lymphoma

Several chemotherapeutic agents are known to develop pulmonary toxicities in cancer patients, although the frequency of incidence varies. Cyclophosphamide is a commonly encountered agent that is toxic to the lung. Additionally, granulocyte colony-stimulating factor (G-CSF) being used for the recovery from neutropenia can exacerbate lung injury. However, most of the patients reported previously that the drug-induced interstitial pneumonitis were developed after three to four cycles of chemotherapy. Hereby, we report a case of peripheral T cell lymphoma which rapidly developed a fatal interstitial pneumonitis after the first cycle of combined chemotherapy with cyclophosphamide, adriamycin, vincristine, prednisolone, and etoposide and the patient had also treated with G-CSF during neutropenic period.

Management of uncommon chemotherapy-induced emergencies

Chemotherapy can induce various clinical emergencies. Prompt recognition and management of these adverse events are important for avoiding further morbidity and mortality. Some events such as hypersensitivity and extravasation are quite common, whereas emergencies such as neutropenic typhlitis, pancreatitis, and acute haemolysis are very rare. Little information exists on the management of rare chemotherapy-induced emergencies that affect fewer than 1% of patients. We review these uncommon chemotherapy-induced life-threatening emergencies, their pathogenesis and management, and recommendations for rechallenge with the offending chemotherapy.

A retrospective seven-year analysis of the use of B cell depletion therapy in systemic lupus erythematosus at University College London Hospital: the first fifty patients

OBJECTIVE

To describe the 6-month clinical outcome and the long-term safety profile of B cell depletion therapy (BCDT) in 50 patients with active systemic lupus erythematosus (SLE), who were nonresponsive or poorly responsive to conventional immunosuppression.

METHODS

All except 4 of 50 patients with active SLE received 1 gm of rituximab, 750 mg of cyclophosphamide, and 100-250 mg of methylprednisolone, administered on 2 occasions 2 weeks apart, to achieve B cell depletion. Clinical outcome was assessed using the British Isles Lupus Assessment Group (BILAG) activity index and serial serologic measurements of disease activity. Remission was defined as a change from a BILAG A or B score to a C or D score in every organ system. Partial remission was a change from a BILAG A or B score to a C or D score in at least 1 system, but with the persistence of 1 score of A or B in another system. No improvement was defined as a BILAG A or B score that remained unchanged after treatment.

RESULTS

Of the 45 patients available for followup at 6 months, 19 patients (42%) achieved remission, and 21 patients (47%) reached partial remission after 1 cycle of BCDT (mean followup 39.6 months). BCDT resulted in a decrease in median global BILAG scores from 12 to 5 (P < 0.0001) and median anti-double-stranded DNA antibody titers from 106 to 42 IU/ml (P < 0.0001), and an increase in the median C3 level from 0.81 to 0.95 mg/liter (P < 0.02) at 6 months. Five serious adverse events were observed.

CONCLUSION

BCDT is an effective treatment for patients with active SLE whose disease has failed to respond to standard immunosuppressive therapy. Although the safety profile of BCDT is favorable, ongoing monitoring is required.