Cyclophosphamide-induced interstitial pneumonitis in a patient with ovarian carcinoma

Acquired Platythorax, or Anteroposterior Flattening of the Chest Wall, as a Late Complication of Cyclophosphamide Treatment for Childhood Acute Lymphoblastic Leukemia, Presenting in a Young Man with Respiratory Failure

Patient: Male, 26

Final Diagnosis: Cyclophosphamide-induced pulmonary fibrosis

Symptoms: Platythorax • progressive cardiopulmonary failure

Medication: Cyclophosphamide

Clinical Procedure: Supportive care

Specialty: Oncology

Progressive pulmonary fibrosis complicating cyclophosphamide therapy

A 26-year-old woman with extra-pulmonary Wegener's granulomatosis was treated with cyclophosphamide for 3.25 years, cumulated dose of 91 g. Six months before cessation of therapy discrete radiological signs of apical fibrosis appeared. The changes were progressive regardless of discontinuation of cyclophosphamide and led to severe restrictive ventilatory defect.

Cyclophosphamide-induced acute respiratory distress syndrome

Cyclophosphamide is widely used in neoplastic and inflammatory diseases. Although several adverse events have been described with its use, acute and subacute interstitial pneumonitis leading to pulmonary fibrosis is rare and potentially fatal. This case report describes a 64-year-old man who, after the fifth chemotherapy cycle, developed a severe ARDS leading to pulmonary fibrosis in just 30 days.

Pulmonary fibrosis induced by cyclophosphamide

OBJECTIVE

To report a case of pulmonary fibrosis resulting from use of cyclophosphamide as chemotherapy to treat a patient with breast cancer.

CASE SUMMARY

We describe the case of a 52-year-old woman with breast cancer who developed pulmonary fibrosis after four cycles of chemotherapy that included cyclophosphamide. Pulmonary function tests revealed the presence of a severe ventilatory restriction. The open lung biopsy revealed pulmonary fibrosis with vascular sclerosis and signs of pulmonary hypertension.

DISCUSSION

Cyclophosphamide is an alkylating agent that has been associated with interstitial pneumonia and pulmonary fibrosis. The frequency of these unwanted effects is <1%. The clinical picture consists of the progressive appearance of dyspnea and a non-productive cough that progresses to severe pulmonary insufficiency. The risk factors described for these complications have been the use of chemotherapy regimens that include other drugs with known pulmonary toxicities, the cumulative total dose, the addition of radiotherapy, and the use of high doses of cyclophosphamide.

CONCLUSIONS

Even though the frequency of pulmonary fibrosis in patients treated with cyclophosphamide-based chemotherapy regimens is low, the presence of dyspnea and an interstitial pattern in a patient makes it necessary to consider that possible drug toxicity. The open lung biopsy is the most accurate diagnostic technique for these cases. The discontinuation of cyclophosphamide and treatment with corticosteroids is usually followed by clinical recovery in approximately 50% of patients and, in some cases, reversal of the lung injury.

Interstitial pneumonitis probably induced by cyclophosphamide in nephrosis

A case of interstitial shadows associated with oral cyclophosphamide therapy in a 32-month-old girl with steroid-resistant nephrotic syndrome, who was admitted to the Nishi-Kobe Medical Center with systemic edema, is reported. Due to the lack of response to prednisolone, cyclophosphamide was also administered orally at a dose of 3 mg/kg per day, 4 weeks after the start of steroid therapy. Approximately 3 weeks after the combination treatment she developed a fever, dry cough and cyanosis. Radiographic examination showed diffuse ground-glass shadow in both lungs, presumably indicating that she had interstitial pneumonitis. Her pulmonary signs and symptoms deteriorated despite various antimicrobial treatments. A discontinuation of cyclophosphamide and the administration of high-dose methylprednisolone yielded a dramatic improvement. These findings suggest that the diffuse pulmonary disease in this case was induced by cyclophosphamide. Since interstitial pneumonitis may be fatal and irreversible, attention should be paid to this rare complication even in patients undergoing low-dose oral cyclophosphamide treatment.

Antirheumatic drug reactions in the lung

Drug-induced lung disease during treatment with antirheumatic drugs should be considered in all patients receiving these agents who develop new pulmonary symptoms. When a potential drug-related reaction is identified, the possible offending agents should be discontinued, appropriate respiratory support initiated, and a thorough investigation for other causes of respiratory disease launched to exclude infection or other pulmonary processes. Lung biopsy may be needed to define the disorder completely. In patients with acute pneumonitis, the use of corticosteroids should be considered. Although significant morbidity and even mortality may occur with drug-induced pulmonary events, proper and prompt evaluation and treatment of these disorders can often result in complete resolution of the pulmonary disease.

Pulmonary complications of antirheumatic drug therapy

Drug-induced pulmonary disease should be considered in all patients receiving these antirheumatic agents who develop new pulmonary symptoms. When a drug reaction is suspected, the possible offending agents should be discontinued, required respiratory support instituted, and infection or other pulmonary processes excluded. Pathological evaluation by lung biopsy may be needed to define the disorder and rule out infection. Treatment with corticosteroids should be considered in patients with acute pneumonitis. While significant morbidity and even death may occur with drug-induced pulmonary disease, prompt evaluation and treatment of these disorders often results in complete resolution of the process.

Metabolism and pulmonary toxicity of cyclophosphamide

Pulmonary toxicity caused by an antineoplastic drug, cyclophosphamide is becoming a more frequently recognized entity. Metabolism of cyclophosphamide in lung to alkylating metabolites and acrolein, a reactive aldehyde are in part responsible for pulmonary toxicity. Alterations in pulmonary mixed-function oxidase activity, glutathione content, and microsomal lipid peroxidation may be caused by the reactive metabolite acrolein. Potentiation of cyclophosphamide-induced pulmonary injury under hyperoxic conditions is caused by depression of pulmonary antioxidant defense mechanisms by cyclophosphamide and its other metabolites but not acrolein. Cyclophosphamide- and acrolein-induced alterations in the physical state of membrane lipid bilayer may be the major cause of inactivation of membrane-bound enzymes. These data suggest that cyclophosphamide and its reactive metabolites initiate peroxidative injury resulting in alterations in the physical state of membrane lipids which may be functionally linked to manifestations of cyclophosphamide-induced pulmonary toxicity.

Pulmonary toxicity of cytotoxic and immunosuppressive agents. A review

Cytotoxic agents may cause interstitial or eosinophilic pneumonitis, alveolar proteinosis, pulmonary venous occlusive disease, pulmonary fibrosis, pneumothorax, or pulmonary oedema. These agents may also potentiate lung injury caused by radiotherapy or high oxygen fractions in inspired air. Clinical and roentgenological features of lung damage induced by cytotoxic drugs are usually non-specific, and differential diagnoses include progression of the malignant disease and a plethora of opportunistic infections. Monitoring of blood gases and carbon monoxide transfer factor may facilitate early detection of drug induced lung injury. Fiberoptic bronchoscopy, bronchoalveolar lavage, transbronchial biopsy, or open lung biopsy may be necessary for reliable diagnosis. Early detection of lung damage and immediate withdrawal of the responsible agent(s) are essential. Steroids may be of therapeutic value in some patients.

Prognostic factors in borderline and invasive ovarian tumors of the common epithelial type

Present reports show that surgical factors, response to therapy and histological criteria are important for predicting the prognosis of patients with common epithelial types of ovarian tumors. Newer techniques such as morphometry, DNA cytometry, immunological and immunopathological techniques may help to define prognostic factors even more accurately. As a result, these recently developed methods may enhance the value of well-established classical predictors of the outcome in case of borderline or invasive ovarian tumour.