Louise Gribben Haematology CNS HAI 2016 Hodgkin's lymphoma Louise Gribben Haematology CNS HAI 2016

Case study 61 year old female HD on ABVD chemotherapy 6th and final ABVD 9th October Help line call same day Pyrexia, rigors ?bleomycin reaction Developed hacking cough, hypoxic Not neutropenic Had previously had a rigor following bleomycin at cycle 3 d15

… … Picc position xray 2nd october. Pre last chemo

… … BILATERAL INTERSTITIAL INFILTRATE 9/10 /16

Deterioration over 1 week Broad spectrum anti bacterials Increasing SOB No evidence for infective process Increasing oxygen requirements High dose Co-trimoxazole/steroids

… … 14th october

ICU (day 7 post admission) Type 1 respiratory failure/ fibrotic changes Intubated/ ventilated Probable BIP Deceased ( day 18 post admission)

Bleomycin Induced Pneumonitis and Fibrosis Duggan et al 2003 28% of HD ĉ ABVD 224 of 814 patients Martin et al 2005 18% of HD ĉ ABVD 25 of 141 patients 5 died

Side effects Fever, chills, hypotension Dermal pigmentation, fibrosis Stomatitis Fatigue Pulmonary toxicity Bronchiolitis obliterans with organizing pneumonia Interstitial pneumonitis with progression to fibrosis Death – 3%

BIP – Clinical Features Initial Non productive cough Exertional dyspnoea Sometimes fever Progressive Dyspnoea at rest Tachynoea Cyanosis On examination – fine basal creps, progress to rhonchi sometimes pleural rub

Treatment Exclude infection Corticosteroid Stop Bleomycin In survivors, pulmonary symptoms and lung function normalise in time

Adjusted management Specific ABVD prescription charts. Drug specific counselling/consent forms. Pre chemo exercise/oximetry testing Repeated PFT pre each treatment after cycle 3 Avoid use of GCSF products Caution with O2 therapy

In Future Avoid/ Reduce Bleomycin in regimen Nice guidance PET scan can distinguish active inflammation and lung damage