SEVERE CYCLOPHOSPHAMIDE-INDUCED PNEUMONITIS IN A PATIENT WITH BREAST CANCER

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Cyclophosphamide is an alkylating agent and is used for the treatment of various malignant and nonmalignant diseases. Common side effects include alopecia, infertility, bone marrow suppression, and gastrointestinal symptoms. Cyclophosphamide can also cause pneumonitis, a rare side effect with few reported cases. We report a case of pneumonitis with severe hypoxic respiratory failure secondary to cyclophosphamide use. CASE PRESENTATION: A 65-year-old female with triple negative, stage II breast cancer, presented to the ED with a 3-day history of shortness of breath and a worsening dry cough. She had recently completed her fourth cycle of dose-dense neoadjuvant chemotherapy with adriamycin and cyclophosphamide. She was febrile, tachycardic, and hypoxemic with an oxygen saturation of 58%. Due to progressive respiratory failure, she was intubated and admitted to the ICU. CTA of the chest showed segmental right-sided pulmonary emboli with no right heart strain and bilateral diffuse ground glass densities with septal thickening. She was started on heparin, broad spectrum antibiotic coverage, and steroids. BAL demonstrated negative cultures, viral PCR panel, PJP PCR, and showed no eosinophils or malignant cells. Autoimmune workup including ANA, RF, and CCP was also negative. Given the clinical history and negative evaluation for infection, eosinophilic pneumonitis, autoimmune pneumonitis, and low suspicion for lymphangitic carcinomatosis, the patient was diagnosed with cyclophosphamide-induced pneumonitis. She was continued on steroids and showed slow improvement in her condition. DISCUSSION: Severe pneumonitis from cyclophosphamide use is rare toxicity. It can be classified as early or late onset depending on the treatment duration and onset of symptoms. Patients with early onset pneumonitis usually present with progressive dyspnea, cough and occasionally fever and fatigue. These patients have been shown to respond to steroids. CONCLUSIONS: Due to the rapidly progressive nature of the disease and high risk of mortality, physician should be alert to this adverse effect, and treatment with steroids should be initiated as soon as other causes of respiratory failure are ruled out. Reference #1: Ochoa R, Bejarano PA, Glück S, Montero AJ. Pneumonitis and pulmonary fibrosis in a patient receiving adjuvant docetaxel and cyclophosphamide for stage 3 breast cancer: a case report and literature review. J Med Case Rep. 2012;6:413. Published 2012 Nov 30. https://doi.org/10.1186/1752-1947-6-413 Reference #2: Kawajiri H, Takashima T, Onoda N, Kashiwagi S, Ishikawa T, Hirakawa K. Interstitial pneumonia associated with neoadjuvant chemotherapy in breast cancer. Mol Clin Oncol. 2013;1(3):433-436. DISCLOSURES: No relevant relationships by Vishal Deepak, source=Web Response No relevant relationships by Mehdi Farishta, source=Web Response no disclosure on file for Mridul Parmar; No relevant relationships by Spencer Winters, source=Web Response