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

2. 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

3. … …
Picc position xray 2nd october. Pre last chemo

4. … …
BILATERAL INTERSTITIAL INFILTRATE 9/10 /16

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

6. … …
14th october

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

8. Bleomycin Induced Pneumonitis and Fibrosis
Duggan et al % of HD ĉ ABVD
224 of 814 patients
Martin et al % of HD ĉ ABVD
25 of 141 patients
5 died

9. 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%

10. 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

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

12. 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

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