WHAT IS YOUR DIAGNOSIS? * Metastatic disease * Bleomycin-induced lung injury * Pneumocystis carinii pneumonia * Bronchiolitis obliterans organizing pneumonia ?DISCUSSION The angiogram showed diffuse interstitial infiltrates with volume loss. Repeat PFTs demonstrated a moderate restrictive deficit with a significant reduction in diffusing capacity of the lung for carbon monoxide (approximately 50%) from baseline. Renal insufficiency, radiation therapy, or a high fraction of inspired O2 can increase the risk of lung injury.3 Our patient's respiratory symptoms began soon after he completed chemotherapy, but pneumonitis can present more acutely or up to 6 months after treatment has ended.
COTM0509.qxp 4/28/09 11:53 AM Page 76 Case of the Month Michele Taffaro-Neskey, PA-C and oriented. He was afebrile. His BP 10%, although incidence as high as 18% was 109/70 mm Hg; heart rate, 120 has been reported.1,2 Other sequelae in- beats per minute; respiration rate, 22 clude hypersensitivity pneumonitis and breaths per minute. Oxygen (O2) satura- nodular pulmonary densities. Bleomycin tion at rest was 87% on room air and doses greater than 500 mg/m2 are more 93% with 2 L of O2 via nasal cannula. likely to cause pulmonary toxicity. The neck was supple and without jugu- Renal insufficiency, radiation therapy, lar venous distention. Fullness of the or a high fraction of inspired O2 can in- right axilla was noted, but there was no crease the risk of lung injury.3 Our pa- palpable lymphadenopathy. The patient tient’s respiratory symptoms began soon had mild sinus tachycardia; no mur- after he completed chemotherapy, but murs, rubs, or gallops were heard. Aus- pneumonitis can present more acutely FIGURE 1. The CT pulmonary angiogram cultation of the lungs revealed inspirato- or up to 6 months after treatment has revealed diffuse interstitial infiltrates. ry bibasilar crackles and scattered expi- ended. Clinical and radiographic signs ratory wheezing. Air movement was of bleomycin-induced lung injury can ›CASE decreased in both lung fields, which mimic infection or metastatic disease. A 54-year-old male presented with mod- were resonant to percussion. No egoph- History and findings on BAL can pro- erate dyspnea at rest that had been ony was heard. Abdomen was soft, non- vide clues. Bleomycin-induced lung worsening for 3 weeks. He had a dry tender, and nondistended. Extremities injury may be related to the absence of cough but no hemoptysis, chest pain, were without edema, cyanosis, clubbing, pulmonary bleomycin hydrolase.3 orthopnea, or palpitations. Low-grade or palpable cords. Psoriasis was seen on Treatment Typically, treatment com- fevers were relieved with acetamino- the elbows. No neurologic deficits were prises corticosteroids and O2 therapy. phen. To address episodes of hypoten- found. The patient underwent CT pul- Patients may relapse as corticosteroids sion, he had stopped taking atenolol monary angiography (see Figure 1). are tapered. Up to 70% of patients will (Tenormin), but his systolic BPs re- have a short-term response, but alter- mained between 90 and 99 mm Hg. He ›WHAT IS YOUR DIAGNOSIS? ations in PFTs may recur years after denied lower-extremity edema, changes • Metastatic disease treatment, even in patients who have in bowel habits, or signs of GI bleeding. • Bleomycin-induced lung injury responded favorably.4 Patients with History In Decemb
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