A 28-year-old man receiving BEP chemotherapy for stage IIB non-seminomatous germ cell tumour develops an insidious dry cough and exertional breathlessness six weeks into treatment. Chest examination shows fine end-inspiratory crackles, and CT reveals bilateral basal ground-glass change and subpleural reticulation. Infection screen is negative. The most likely cause is:

• A Cisplatin induced interstitial lung disease
• B Etoposide induced secondary leukaemia presenting as pulmonary infiltration
• C Radiation pneumonitis from prophylactic mediastinal irradiation
• D Cumulative bleomycin induced pulmonary fibrosis ✓

Explanation

Bleomycin causes dose-dependent pulmonary toxicity progressing from pneumonitis to fibrosis, classically with dry cough, dyspnoea, basal crackles and basal predominant ground-glass change on CT; risk rises steeply with cumulative dose beyond about 400 units and with concurrent oxygen exposure. Cisplatin and etoposide are not established causes of interstitial lung disease in this setting, and no irradiation was given in this protocol, excluding option C.

Reference: Katzung Basic and Clinical Pharmacology, 16th ed.

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