Chlorambucil-induced pulmonary injury
- Raed A Dweik, MD, FACP, FCCP, FRCP(C), FCCM, FAHA
Raed A Dweik, MD, FACP, FCCP, FRCP(C), FCCM, FAHA
- Professor of Medicine
- Cleveland Clinic Lerner College of Medicine
- Section Editors
- Kevin R Flaherty, MD, MS
Kevin R Flaherty, MD, MS
- Section Editor — Interstitial Lung Disease
- Associate Professor of Medicine
- University of Michigan Health System
- James R Jett, MD
James R Jett, MD
- Section Editor — Lung Cancer
- Professor of Medicine Emeritus
- National Jewish Health
- Deputy Editors
- Helen Hollingsworth, MD
Helen Hollingsworth, MD
- Deputy Editor — Pulmonary, Critical Care, and Sleep Medicine
- Associate Professor of Medicine
- Boston University School of Medicine
- Diane MF Savarese, MD
Diane MF Savarese, MD
- Senior Deputy Editor — UpToDate
- Deputy Editor — Oncology and Palliative Care
- Clinical Instructor of Medicine
- Harvard Medical School
Chlorambucil is an alkylating chemotherapy agent. It can be given orally and is mainly used in the treatment of chronic lymphocytic leukemia (CLL). It has also been used as an immunosuppressive agent in autoimmune and inflammatory conditions like rheumatoid arthritis and sarcoidosis. Other than myelosuppression, less common side effects of chlorambucil involve the gastrointestinal tract, liver, skin, and the central nervous system. Lung toxicity is rare but well documented [1-16]. (See "General toxicity of cyclophosphamide in rheumatic diseases".)
While the pulmonary toxicity of other alkylating agents like busulfan and cyclophosphamide is well recognized , chlorambucil-induced pulmonary injury is uncommon in spite of its wide use as an antineoplastic agent . The literature is confined to isolated, but well-documented case reports [3-9,11-13,15,16,18,19]. There is no direct correlation between the dose or duration of therapy and the incidence of lung toxicity . Doses of chlorambucil ranging from 540 to 8340 mg have been reported [4,9].
The most common pattern of lung injury reported in chlorambucil pulmonary toxicity is chronic interstitial pneumonitis, but acute interstitial pneumonitis and organizing pneumonia (formerly known as bronchiolitis obliterans organizing pneumonia or BOOP) have also been reported [6,8,19]. Evidence of interstitial lung disease may develop while the patient is taking chlorambucil or after stopping it.
In chronic interstitial pneumonitis, symptoms usually develop six months to three years or longer after initiation of therapy; the most common presentation is the insidious onset of cough and dyspnea. Other symptoms may include weight loss, fever, and hemoptysis. Physical examination reveals fine basilar crackles and fever . Recurrent episodes of acute respiratory distress with exposure to the drug have also been described [3,12,16].
Similar to other cases of drug-induced lung disease, the diagnosis requires a high index of suspicion in the appropriate clinical setting. The final diagnosis is made after exclusion of other etiologies for the clinical presentation, especially infection. Other considerations in the differential diagnosis include leukemic infiltrates, alveolar hemorrhage, radiation pneumonitis, and other drug toxicities. (See "Approach to the immunocompromised patient with fever and pulmonary infiltrates".)
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