Case Report
 
Simultaneous bilateral spontaneous pneumothorax and radiation pneumonitis following thoracic radiotherapy for the treatment of high grade follicular lymphoma
Dalia Mudawi1, George Antunes2, Rajesh Mamadigi3
1Stepping Hill Hospital, Stockport, SK2 7JE, UK
2James Cook University hospital, Marton Road, Middlesbrough, TS4 3BW, UK
3James Cook University Hospital, Marton Road, Middlesbrough, TS4 3B, UK

Article ID: 100050Z10DM2018
doi: 10.5348/100050Z10DM2018CR

Corresponding Author:
Dalia Mudawi,
Stepping Hill Hospital,
Stockport, SK2 7JE, UK

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How to cite this article
Mudawi D, Antunes G, Mamadigi R. Simultaneous bilateral spontaneous pneumothorax and radiation pneumonitis following thoracic radiotherapy for the treatment of high grade follicular lymphoma. J Case Rep Images Oncology 2018;4:100050Z10DM2018.


ABSTRACT

Introduction: Spontaneous pneumothorax is a potentially life-threatening condition but an under-recognised and rarely described complication of thoracic radiotherapy. We report a case of bilateral spontaneous pneumothoraces and radiation pneumonitis following moderate dose of thoracic radiation to the spine for high grade follicular lymphoma.

Case Report: A 66-year-old Caucasian male, non-smoker and no pre-existing pulmonary pathology, was diagnosed with low grade follicular lymphoma in 1999 and treated with chlorambucil and dexamethasone, followed by 30Gy radiotherapy to para-aortic lymph nodes. A subsequent relapse in 2005 was treated with a further eight cycles of chlorambucil and dexamethasone followed by radiotherapy to the pelvis. A second relapse in 2009 was managed with eight cycles of cyclophosphamide, vincristine and prednisolone and rituximab (CVP-R), followed by two years of maintenance rituximab. In 2016, the patient presented with thoracic back pain. Magnetic resonance imaging (MRI) demonstrated diffuse bony metastasis particularly at levels T2-T4 compressing the spinal cord that was decompressed surgically. Biopsy confirmed diffuse large B-cell lymphoma. He received intensive chemotherapy comprising of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP) and intrathecal methotrexate. He received consolidation radiotherapy totalling 30Gy over 15 fractions to the thoracic spine at levels T2-T4 and left humerus. The patient presented to secondary care within eight weeks of completing thoracic radiotherapy complaining of worsening dyspnoea on exertion. Arterial blood gas analysis confirmed hypoxemic respiratory failure and computed tomography (CT) scan of the thorax demonstrated bilateral small to moderate sized pneumothoraces, bilateral patchy ground glass opacification suggestive of radiation pneumonitis, and atelectasis. The patient was started on a tapering course of high dose systemic corticosteroids leading to a rapid improvement in clinical symptoms and oxygenation. The pneumothoraces were monitored closely and required no intervention. Chest radiograph performed six weeks post completion of treatment showed complete resolution of the pneumothoraces and clear lung fields.

Conclusion: The case highlights a rare but serious complication that presented at a relatively early stage after radiotherapy and the use of a moderate radiation dose. Vigilance of this complication is recommended and should be considered in the differential diagnosis of a patient presenting with dyspnoea after thoracic radiotherapy.

Keywords: Bilateral pneumothorax, Radiation pneumonitis, Lymphoma


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Author Contributions
Dalia Mudawi – Substantial contributions to conception and design, Acquisition of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
George Antunes – Substantial contributions to conception and design, Acquisition of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Rajesh Mamadigi – Acquisition of data, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of Submission
The corresponding author is the guarantor of submission.
Source of Support
None
Consent Statement
Written informed consent was obtained from the patient for publication of this case report.
Conflict of Interest
Author declares no conflict of interest.
Copyright
© 2018 Dalia Mudawi et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.