It's Not Always Pneumonia: Bleomycin-Induced Lung Injury in a Patient with HIV

Abstract

INTRODUCTION: Bleomycin is an antitumor agent most often used to treat Hodgkin lymphoma. The use of bleomycin is limited by potential for oxidative lung damage. Incidence correlates with cumulative dose, with most cases occurring with >400 international units (IU). Here we present an expository case of bleomycin-induced lung injury at an unusually low dose with additional important diagnostic considerations. CASE SUMMARY: A 37-year-old woman with a past medical history of HIV, Hodgkin's lymphoma, and renal failure requiring dialysis was evaluated for dyspnea and dry cough. The patient had completed three cycles of chemotherapy with ABVD (Doxorubicin, Bleomycin, Vinblastine, Dacarbazine). The cumulative dose of bleomycin was 32 IU. On examination, the patient was cachectic with mild bibasilar crackles noted on lung auscultation. The oxygen saturation was 97% while receiving supplemental oxygen at 2 liters per minute by nasal cannula. The CD4 count was 220. Chest radiography revealed patchy infiltrates scattered throughout both lungs not present on imaging five months prior. High-resolution CT showed widespread interstitial thickening and diffuse ground-glass opacities. Broad-spectrum antibiotics were started for suspected community acquired pneumonia to no effect. Further laboratory testing and bronchoalveolar lavage ruled out infectious etiology, including PCP and COVID19. Subsequent VATS and wedge resection was performed. Pathology demonstrated interstitial cellular infiltrate and fibrosis. A diagnosis of organizing pneumonia possibly related to bleomycin was made. Future treatment with bleomycin was discontinued. Systemic glucocorticoids were administered. Despite initial improvement, the patient's clinical course was complicated by hypoxemic respiratory failure, for which she underwent intubation and mechanical ventilation. She died on hospital day 30. No postmortem examination was performed. DISCUSSION: The diagnosis of bleomycin-induced lung injury is one of exclusion;often made within weeks of chemotherapy administration and rarely after six months. In this case, concurrent infection with HIV prolonged the time to diagnosis due to high clinical suspicion for atypical pneumonia. Moreover, the patient's limited renal function likely narrowed the chemotherapeutic safety window, given bleomycin is eliminated almost entirely by the kidney. Our case illustrates the importance of early consideration of this entity even at doses not routinely associated with toxicity. Upon diagnosis, treatment is immediate cessation of the causative agent followed by systemic glucocorticoids. The prognosis is grim, with most patients succumbing to respiratory failure within months of symptom onset.