18 Jun 2021

12/16/20: Pneumomediastinum 2/2 Bleomycin toxicity

PGY2 Moses Koo presented a case of a 28 year old male with history of non-seminomatous testicular cancer s/p BEP x4 cycles who presents with worsening shortness of breath for the last week.  Per patient, he has had SOB for the last 3 weeks but acutely worsening 3 days prior.  Patient at baseline is able to walk 3-4 blocks without moderate SOB but now can only walk 10 ft.  Of note, patient finished chemo regimen 1 week ago and has been experiencing nausea and vomiting but reports this is usual and has tolerated previous cycles without significant symptoms.  Denies chest pain, SOB at rest, abdominal pain, weakness, paresthesia or urinary symptoms.  Does report pleuritic pain on deep inspiration, mild cough and neck pain/discomfort exacerbated by movement.  Denies trauma, new sputum production, hemoptysis, fevers, sick contacts or recent travel.  Home medications include amlodipine 5mg qday, ondansetron PRN and metoclopramide PRN.  He lives with his mothers, works in janitorial service.  Reports smoking marijuana for several years but recently quit.  Denies any alcohol, tobacco/other drug use.

Vitals: T 37.1, HR 100, RR 22,  BP 137/81, O2 sat 100% on RA

Physical Exam significant for comfortable and conversational male, mild cervical tenderness, normal cardiac and pulm exam, hyperpigmented palm spots.

CBC: WBC 2.6> Hb 9.1/Hct 25.3 <Plt 203 (MCV 86, RDW 15.1%)

CMP:

Na 129/K 3.1/Cl 84/HCO3 27/BUN 17/Cr 0.86<Glucose 116

ALP 74>T.protein 6.2/Albumin 4.1/AST 12/ALT 12/Tbili 1.1/Dbili 0.4

Ca 9.2, Mg 1.9, Phos 2.8

Coags: PT 17, INR 1.42, PTT 36.4

Infectious workup initiated, with the following findings:

  • BCx, Fungal Cx, UA, UCx negative
  • HIV, RPR negative
  • SARS-CoV-2 not detected

Oncology labs:

  • AFP 4.9 (normal <8.3), compare to 23.4 one month prior
  • B-HCG <1
  • LDH 214 U/L (normal: 135-225)

Cardiology/Pulm workup:

  • Troponin <0.01
  • EKG showed sinus tachycardia:
  • CXR shows diffuse bilateral lower lobe predominant subpleural patchy ground glass opacities.  Extensive pneumomediastinum, trace pneumopericardium and trace L pneumothorax with subcutaneous emphysema of the neck and R chest wall.
  • CT Thorax w/ contrast shows pneumomediastinum with air extending up into the neck region likely secondary to bleomycin toxicity

Treatment: After infection was ruled out, patient was started on IV solumedrol 1mg/kg per oncology recommendation and given improvement in symptoms, he was discharged with continued outpatient PO steroids.

Teaching points:

  1. Pneumomediastinum = presence of air in the mediastinum, divided into spontaneous (asthma, CF, infections, smoking, substance abuse) vs secondary (endoscopic procedures, invasive airway ventilation, central vascular procedures, thoracic surgery, trauma)
  2. Sx: chest pain radiating to back or up the neck along with acute dyspnea
  3. Bleomycin toxicity: pneumonitis, pulmonary fibrosis, stomatitis and Raynaud’s phenomenon
  4. Worsening outcome of lung pathology if patients are exposed to supplementary O2 while having received bleomycin
  5. Tx: conservative, address underlying causes, avoid supplemental O2 (if bleomycin induced) and +/- steroids to taper the effect of bleomycin induced generation of free radical species and subsequent cytokine local release

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