DELAYED ONSET BLEOMYCIN-INDUCED PNEUMONITIS I. UZEL, M. OZGUROGLU, B. UZEL, K. KAYNAK, O. DEMIRHAN, C. AKMAN, F. OZ, AND M. YAMAN ABSTRACT We describe a 39-year-old male patient who developed bleomycin-induced pneumonitis 2 years after completion of chemotherapy for nonseminomatous testicular cancer. Bleomycin sometimes causes fatal pulmonary toxicity, including bleomycin-induced pneumonitis. The central event in the development of pneumonitis is endothelial damage of the lung vasculature due to bleomycin-induced cytokines and free radicals. Pulmonary toxicity usually begins at bleomycin administration. The development of bleomycin- induced pneumonitis up to 6 months after bleomycin therapy has also been reported. We report a patient who developed bleomycin-induced pneumonitis 2 years after the initiation of bleomycin-containing chemo- therapy regimens. UROLOGY 66: 195e.23–195e.25, 2005. © 2005 Elsevier Inc. B leomycin is an antitumor antibiotic that is used for the treatment of several malignancies, in- cluding germ cell tumors, Hodgkin’s and non- Hodgkin’s lymphomas, and squamous cell carci- noma of the head and neck, esophagus, and cervix. 1 The most feared and dose-limiting side ef- fect of bleomycin is its induction of pulmonary toxicity. Bleomycin-induced pneumonitis (BIP) occurs in 0% to 46% of the patients treated with bleomycin-containing chemotherapy. 2 The mor- tality of patients with BIP has been reported to be approximately 3%. 3,4 We report a unique case of delayed-onset pulmo- nary toxicity in a 39-year-old patient with testicu- lar cancer who developed BIP 2 years after the ini- tiation of chemotherapy. CASE REPORT A 39-year-old man was found to have a mixed germ cell tumor of the left testis (seminoma plus embryonal cell carcinoma and endodermal sinus tumor) after left orchiectomy. He was a nonsmoker and had not used any illicit drugs or alcohol. The metastatic workup with computed tomography (CT) of the chest and abdomen showed retroperi- toneal paraaortic lymphadenopathy and three pa- renchymal nodules in the left lung. He was treated with a standard combination chemotherapy regi- men consisting of cisplatin 20 mg/m 2 on days 1 to 5, etoposide 100 mg/m 2 on days 1 to 5, and bleo- mycin 30 U on days 2, 8, and 15 (BEP regimen) for three cycles. He received a total of 270 mg of bleo- mycin. Reevaluation of the metastatic lesions re- vealed only one nodule with a 1-cm diameter in the lower lobe of the left lung and complete regression of the paraaortic lymphadenopathies in the abdo- men. Metastasectomy of the pulmonary nodule showed only tumor necrosis. Routine follow-up was planned without any need for additional che- motherapy. The patient was completely asymp- tomatic regarding respiratory symptoms. His pul- monary functions were within normal limits at treatment and during the follow-up period. Twenty-four months after the initiation of the BEP regimen, the patient presented with dyspnea, low-grade fever, sweating, and tiredness. CT of the chest showed micronodular infiltration in the right upper lobe, suggestive of pulmonary tuberculosis. Pulmonary function tests showed a severe restric- tive ventilatory defect. Bronchoscopy showed no endobronchial pathologic features. Transbron- chial biopsy revealed nonspecific chronic inflam- mation, desquamation, and alveolar damage. On bronchial lavage, no sign of malignancy or tuber- culosis was detected. Bronchoalveolar lavage fluid showed 60% alveolar macrophages, 16% polymor- phonuclear leukocytes, 18% lymphocytes, 5% eo- sinophils, and 2% basophils. The patient refused From the Departments of Pulmonary Diseases, Medical Oncol- ogy, Thoracic Surgery, Radiology, and Pathology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey Address for correspondence: Mustafa Ozguroglu, M.D., Çiçekçi Bostan sok., Mesa koru evleri, C1/1 Altunizade, Istanbul, Turkey. E-mail:ozguroglu@superonline.com Submitted: October 27, 2004, accepted (with revisions): Janu- ary 19, 2005 CASE REPORT © 2005 ELSEVIER INC. 0090-4295/05/$30.00 ALL RIGHTS RESERVED doi:10.1016/j.urology.2005.01.038 195.e23