Antineoplastics

Abstract

Drug-related pneumonia with hypersensitivity pneumonitis pattern with various other toxicities: 3 case reportsIn a retrospective study of 133 patients diagnosed with drug-related pneumonitis (DRP) between October 2013 and October 2019, three patients including two men and one woman aged 51-77 years were described who developed DRP with hypersensitivity pneumonitis (HP) pattern during treatment with paclitaxel, everolimus or nivolumab. Additionally, one patients developed lower limb pain, renal failure or lack of efficacy during treatment with capecitabine, oxaliplatin, trastuzumab, nivolumab, cisplatin, vinorelbine, carboplatin or paclitaxel [routes not stated; not all dosages, duration of treatments to reactions onset and outcomes stated].Case 1: A 77-year-old man developed DRP with hypersensitivity pneumonitis (HP) pattern during treatment with paclitaxel for metastatic advanced gastric cancer. Additionally, he developed lower limb pain during treatment with capecitabine, oxaliplatin and trastuzumab and renal failure during treatment with nivolumab. The man, who had smoking history and no recent history of exposure to dust, started receiving first-line chemotherapy with capecitabine, oxaliplatin and trastuzumab. He had been receiving various regular home medications. However, he developed chemotherapy-related lower limb pain. After four cycles, he developed prolonged nausea and fatigue [aetiologies not stated]. He had progression of gastric cancer and gastric dilation with gastric outlet obstruction requiring laparoscopic gastrojejunostomy. He was discharged 2 weeks after surgery. He was started on unspecified antipyretic and analgesic drug for fever, postoperative pain and lower limb pain. Thereafter, he started receiving second-line therapy with nano albumin-bound (nab)-paclitaxel and ramucirumab. On day 8 after the first cycle, paclitaxel was interrupted due to neutropenia [aetiology not stated]. On day 18, he had a high-grade fever and malaise. Therefore, he was treated with levofloxacin. On day 22, a chest CT scan revealed an abnormal shadow in the lung fields. He was referred to current facility. On admission, a peripheral blood test revealed elevated CRP and decreased arterial partial pressure of oxygen (PaO2). A repeat chest CT scan suggested a non-fibrotic typical HP pattern. A bronchoalveolar lavage (BAL) revealed increased lymphocyte count. Culture of BAL fluid yielded negative infectious aetiologies. A transbronchial lung biopsy (TBLB) revealed fibro-cellular alveolitis and accumulation of histiocytes without granulomas. He was diagnosed as grade 2 DRP with radiographic HP pattern, probably due to paclitaxel, after excluding other possible causes. The score on Naranjo causality assessment scale was 5 indicating probable association between paclitaxel and DRP with HP pattern. Chemotherapy was discontinued, and his condition was carefully monitored. On day 33 of the admission, he was treated with pulse methylprednisolone for 3 days. His fever and abnormal shadow improved, without maintenance of steroi...