A Caucasian 68-year-old non-smoker female, without a significant medical history except for hypertension and family history of pancreatic cancer, underwent total splenopancreatectomy for ductal adenocarcinoma associated with branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) of the neck of the pancreas. Since May to September 2014 she received adjuvant treatment in another hospital: 3 cycles of weekly gemcitabine (1000 mg m-2) followed by chemoradiation with gemcitabine (50.4 Gy in 28 fr). A thoracoabdominopelvic computer-assisted tomography (TAP-CT) performed in March 2015 showed the presence of cancer recurrence locally, in retroperitoneal lymph nodes and in lungs. A positron emission tomography with 18-fluoro-deoxyglucose was also performed in order to confirm the diagnosis of relapse. Since April 2015 the patient received first-line chemotherapy at our oncology department. We administered gemcitabine plus nab-paclitaxel combination (gemcitabine 1000 mg m-2 and nab-paclitaxel 125 mg m-2 on days 1, 8 and 15 every 4 weeks) for 12 cycles. The CT scans performed every two cycles showed stable disease, while a metabolic response was seen on positron emission tomography with 18-fluoro-deoxyglucose.
Following the administration of cycle 12, day 15 of gemcitabine plus nab-paclitaxel, the patient experienced low-grade pyrexia, effort dyspnoea, persistent non-productive cough and malaise. She was empirically treated with a 5-day course of levofloxacin as outpatient, without any beneficial effects, and for the worsening of the symptoms she was eventually hospitalized. On admission, blood examination revealed moderate anaemia (haemoglobin 9.3 g dl-1) and an increased level of C-reactive protein (8.2 mg dl-1), whereas white cell differential count, electrolytes and glucose levels and renal and liver function were within normal limits. A chest X-ray showed diffuse reduction of normal lung lucency, both perihilar and peripherical. High-resolution computed tomography (HRCT) scan showed new-onset bilateral peripheral ground-glass opacities, smooth interlobular septal thickening and patchy subpleural consolidation areas. These findings were consistent with OP (Figure 1).
Blood cultures were negative, as well as urine was negative for Legionella and Pneumococcal antigens. Serology tests for Mycoplasma, Legionella, cytomegalovirus, Epstein-Barr virus, adenovirus, influenza, parainfluenza and respiratory syncitial virus were negative, as was the Quantiferon-TB gold In-tube. The patient underwent bronchoscopy for bronchoalveolar lavage, and cytopathological and microbiological analyses were negative for infectious causes; the cell findings in bronchoalveolar lavage fluid were total cell count 271,000 ml-1; macrophages 60%; lymphocytes 30%; neutrophils 10%; eosinophils 0%; no neoplastic cells. Chronic medications at diagnosis consisted in pancreatic enzyme supplements, insulin, amlodipine, pantoprazole and furosemide.
Suspecting chemotherapy-induced pneumonitis, nab-paclitaxel and gemcitabine were discontinued; the patient was started on treatment with prednisone 1 mg kg-1 day-1, which led to rapid clinical improvement. HRCT scan performed after 2 months showed disappearance of alveolar infiltrates and complete resolution of consolidation (Figure 2).