SESSION TITLE: Pleural Case Report Posters
SESSION TYPE: Affiliate Case Report Poster
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: We report, to our knowledge, the first case of Carmustine-associated pneumonitis presenting with a unilateral pleural effusion.
CASE PRESENTATION: A 62-year old male presented with a right pleural effusion as well as mediastinal and hilar lymphadenopathy. Mantle cell lymphoma was diagnosed by transbronchial lymph node biopsy and pleural fluid cytology. He underwent 6 cycles of chemotherapy and achieved complete remission on PET CT. He subsequently underwent autologous bone marrow transplant with a conditioning regimen of Carmustine 550mg/m2 (1122mg), Etoposide 60mg/kg and Cyclophosphamide 100mg/kg. Five weeks later, he reported worsening fatigue and dyspnea on exertion. A CT thorax revealed a large right-sided pleural effusion with associated patchy ground glass opacities affecting multiple lobes (Figure 1). Pleural fluid (Table 1) analysis revealed a lymphocytic predominant, exudative process. Microbiological and cytological assays were all negative. An ultrasensitive assay (ClonoSIGHT, Sequenta, CA) was negative for recurrent lymphoma. Cardiac function was within normal limits. Following a lack of response to empiric antibiotics, the patient was started on prednisone 1mg/kg, which resulted in a rapid improvement of symptoms. A repeat chest radiograph demonstrated near resolution of the pleural effusion and he had corresponding improvements in pulmonary function tests.
DISCUSSION: Carmustine induced pulmonary toxicity has been previously reported to cause bilateral pleural and pericardial effusions . In our case the occurrence of symptoms after conditioning with high dose Carmustine (>1000mg), diffuse ground glass infiltrates on CT and remarkable response to corticosteroids favors the diagnosis of Delayed Pulmonary Toxicity Syndrome (DPTS) over the Idiopathic Pneumonia Syndrome (IPS) . It was necessary to exclude infection and the relapse of lymphoma in this patient with an exudative and predominantly lymphocytic pleural effusion. This patient may have been predisposed to develop this unique presentation of DPTS, as he previously presented with a lymphoma positive pleural effusion affecting the same hemithorax, which may have resulted in a partial defect of the lymphatic drainage of his right hemithorax
CONCLUSIONS: Carmustine-associated DPTS can present as a unilateral pleural effusion. Prompt initiation of steroids upon establishing this diagnosis should lead to the rapid improvement of symptoms.
Reference #1: Krishnan, G.S. et al., Ann Transplant, 2008
Reference #2: Panoskaltsis-Mortari, A. et al, AJRCCM 2011
DISCLOSURE: The following authors have nothing to disclose: Chunrong Lin, Kapilkumar Patel, Joe Hsu
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