Introduction: Bleomycin is a chemotherapy agent used in treating both solid tumors and lymphomas that exerts cytotoxic effects via disruption of DNA integrity through the generation of free radicals and subsequent inhibition of DNA synthesis. Pulmonary toxicity occurs in approximately 10% of patients treated with bleomycin, with the most frequent presentation being pneumonitis, which can progress to pulmonary fibrosis. This case details the clinical course of a patient with severe bleomycin-induced pulmonary fibrosis who ultimately required mechanical ventilation, extracorporeal membrane oxygenation (ECMO), and finally, bilateral lung transplantation. Description: The patient is a 38-year-old male with a past medical history of germ cell testicular cancer and secondary malignant neoplasm of the retroperitoneum and peritoneum, recently treated with bleomycin, etoposide, and paclitaxel, who presented to the hospital for a one-week history of progressive dyspnea. Upon evaluation, the patient was hypoxic to 81% and required nasal cannula. CT thorax demonstrated diffuse chronic interstitial opacities with multifocal areas of irregular consolidation and significant progression of ground glass opacities compared to CT imaging two weeks prior. Broad spectrum antibiotics were initiated, however bronchoscopy was unremarkable for infection. Pulmonology was consulted and the patient was started on pulse dose steroids for suspected bleomycin toxicity. Ten days into hospitalization, the patient was intubated for respiratory failure. Shortly after, he was started on inhaled nitrous oxide. Despite these measures, oxygenation continued to worsen and the patient was started on veno-venous ECMO. Given his deteriorating clinical course, he was evaluated for lung transplant which he underwent nearly 6 weeks after presentation. Discussion: Although many patients with bleomycin-induced lung toxicity recover with supportive care, a small subset of patients may develop a progressive, fibrotic lung disease. The risk of toxicity is strongly associated with advanced age, reduced kidney function, and cumulative bleomycin doses exceeding 300 units. Our patient had a cumulative bleomycin dose of approximately 390 units, but he did not have any of the other risk factors.
Glover et al. (Sun,) studied this question.