Pulmonary Toxicity of Bleomycin – A Case Series from a Tertiary Care Center in Southern India

Abstract

A 22-year-old male who presented with complaints of swelling in the right side of neck and cough with mucoid expectoration was diagnosed to have Hodgkin's lymphoma, stage 2B and was started on 6 cycles of ABVD (Adriamycin, Bleomycin, Vincristine, Dacarbazine) regimen from January 2004 to June 2004, followed by IFRT (Involved Field Radiotherapy). Patient was in complete remission post radiotherapy and was kept under regular follow up.After 10 years, he again presented with right inguinal lymphadenopathy and biopsy was suggestive of Hodgkin's lymphoma. Staging evaluation showed involvement of bone marrow and hence was diagnosed as having relapsed Hodgkin's lymphoma stage 4A. He was started on COPP/ABV regimen (Cyclophosphamide, Oncovin, Prednisone, Procarbazine, Adriamycin, Bleomycin, Vinblastine) with the dose of the offending drug Bleomycin being 15 IU in 100ml 0.9% normal saline. Two weeks after the last chemotherapy cycle 4, patient presented with complaints of breathlessness on exertion which was insidious and progressive and hence was admitted in intensive care unit. High Resolution Computed Tomography (HRCT) thorax showed septal thickening with interspersed areas of ground glass attenuation predominantly in basal and pleural aspects with an associated impression of interstitial lung disease [Table/ Fig-1]. In view of above presentation and computed tomography (CT) findings and drop in saturation, patient was started on non-invasive ventilation, steroids ABSTRACTHodgkin's lymphoma is one of the curable cancers and the standard treatment regimen involves combination chemotherapy involving bleomycin. One of the fatal side effect of bleomycin is pulmonary toxicity. Here we present three cases of Hodgkin's lymphoma treated with ABVD chemotherapy who had pulmonary toxicity. All three developed bleomycin induced pulmonary toxicity in the form of pulmonary fibrosis during treatment of the disease. Mode of treatment, severity of the condition and the treatment outcome varied among the three. Two recovered following treatment and one patient died due to irreversible pulmonary damage. Causality assessment using Naranjo's scale gave a score of 7 for case one and three and a score of 6 for case two, both indicating the adverse drug reaction to be a probable bleomycin induced Lung fibrosis.

Pulmonary Hypertension Induced by Anticancer Drugs

“…Bleomycin, another chemotherapeutic drug belonging to the class of the antibiotics and commonly used for the treatment of lymphomas, is also associated with the occurrence of PH [23]. The overall risk of pulmonary toxicity is about 10%.…”

Bleomycin‐induced pulmonary toxicity and treatment with infliximab: A case report

“…Survival of patients with respiratory failure requiring intensive care unit (ICU) admission is uncertain. Case reports in the published literature suggest that outcomes are often dismal …”

“…Case reports in the published literature suggest that outcomes are often dismal. [4][5][6][7] The mechanism of bleomycin toxicity is unclear and likely multifactorial. Oxidative damage, release of inflammatory cytokines, a deficiency of the bleomycin hydroxylase enzyme in the lungs and genetic predisposition have been described.…”

Bleomycin-Induced Reversible Acute Interstitial Pneumonia

“…The latter, bleomycin-induced pneumonitis (BIP) has an incidence ranging from 0% to 46% with a reasonable estimate of BIP incidence being 10% [6]. Mortality ranges up to 10% [7]. Common symptoms include dyspnea, clubbing, nonproductive cough, pneumonitis, tachypnea, cyanosis with end-inspiratory bibasilar crepitation's, and pleural rubbing.…”