B80-6-09 Bleomycin Lung Toxicity Complicated by Spontaneous Pneumomediastinum and Bilateral Pneumothoraces in the Absence of Known Risk Factors Leading to ARDS

Abstract Introduction Lung toxicity secondary to bleomycin is a well-known complication of first line therapy for several treatable malignancies and is a primary driver of morbidity and mortality in this population. We present an unusual case of rapid bleomycin-induced pneumonitis (BIP) in a patient with no known risk factors. Case A 33-year-old male with stage IIIB left testicular nonseminomatous germ cell tumor with pulmonary metastases, status-post radical orchiectomy and chemotherapy with bleomycin, etoposide, and cisplatin (BEP), presented with a two-day history of worsening dyspnea, pleuritic chest pain, and right-sided neck pain. He had a CT chest one week prior with new mild ground glass opacities. He was tachycardic and hypoxemic with oxygen saturation of 88% on room air. Physical examination revealed right-sided neck crepitus, tachypnea, and bibasilar crackles. On admission, repeat imaging demonstrated new pneumomediastinum, bilateral pneumothoraces, and extensive irregular ground-glass and consolidative opacities, most prominent in the lower lobes. He was started on intravenous methylprednisolone 1mg/kg daily in addition to empiric ceftriaxone and azithromycin for community-acquired pneumonia coverage. His hypoxemia worsened, necessitating transfer to the intensive care unit for mechanical ventilation. Repeat CT angiography was negative for pulmonary embolism, but showed interval worsening of pneumomediastinum with new bilateral spontaneous pneumothoraces. He was trialed on pulse-dose methylprednisolone for three days in addition to intravenous immunoglobulin (IVIG). Chest tubes were placed for management of bilateral pneumothoraces. Given persistent deterioration despite the above, imatinib was initiated as salvage treatment for presumed steroid-refractory BIP, based on limited case reports. However, his condition continued to decline, progressing to severe acute respiratory distress syndrome (ARDS). Neuromuscular blockade and proning were attempted without improvement in his respiratory status. After discussion with his healthcare proxy, he was compassionately extubated and passed away peacefully. Discussion Previous risk stratification of bleomycin toxicity has suggested that age (40), cumulative dose 300IU and reduced kidney function are key risk factors, however none were present in this rapidly progressive case. Key management strategies included high dose steroids (1 mg/kg methylprednisolone), aggressive oxygenation targets to minimize oxygen induced injury targeting aPO2 65, management of pneumothorax with 4x pigtail catheters and usage of imatinib. Conclusion Bleomycin induced lung toxicity continues to be a key driver of mortality in otherwise curable cancers. This case underscores the need for early recognition of bleomycin toxicity even in low-risk groups, and further investigation of management strategies particularly in cases complicated by ARDS. This abstract is funded by: None