Nonspecific interstitial pneumonitis after bortezomib and thalidomide treatment in a multiple myeloma patient

Abstract

Bortezomib, an inhibitor of 26S proteosome, is recently approved treatment option for multiple myeloma. Thalidomide, a drug with immunomodulating and antiangiogenic effects, has also shown promise as an effective treatment in multiple myeloma. Pulmonary complications are believed to be rare, especially interstitial lung disease. Here, we describe a patient with dyspnea and diffuse pulmonary infiltrates while receiving bortezomib and thalidomide in combination with dexamethasone for treatment-naïve multiple myeloma. Bronchoalveolar lavage demonstrated a significant decrease in the ratio of CD4 : CD8 T lymphocytes (CD4/8 ratio, 0.54). Extensive workup for other causes, including infections, was negative. A lung biopsy under video-assisted thorascopic surgery revealed a diagnosis of nonspecific interstitial pneumonitis. The symptoms and imaging study findings improved after initiating steroid treatment. Physicians should be aware of this potential complication in patients receiving the novel molecular-targeted antineoplastic agents, bortezomib and thalidomide, who present with dyspnea and new pulmonary infiltrates and fail to improve despite treatment with broad-spectrum antibiotics.

Fig. 1

Chest CT scans. (A and B) After the first cycle of triple regimen, at the time of clinical deterioration demonstrating newly developed subpleural reticulation and diffuse interstitial changes in both upper and mid-lungs with a ground glass appearance. (C and D) Six weeks after initiating the steroid treatment with marked improvement of interstitial pneumonitis.

Fig. 2

Video-assisted thoracoscopic lung biopsy photomicrographs (Hematoxylin Eosin staining). (A) Alveolar walls are thickened with diffuse interstitial fibrosis (original magnification ×12). (B) Interstitial fibrosis with characteristic temporal monogeneity is present with associated chronic interstitial inflammation, whereas fibroblastic foci are not seen (original magnification ×100).