Q&A: Pulmonary Complications of Cytotoxics: Pleural Friction Rub

Adverse drug reactions (ADRs) due to antineoplastic agents are a common form of iatrogenic injury, and the lungs are a frequent target, as they process the entire cardiac output. While some antineoplastic agent-induced ADRs are potentially preventable (particularly those that are related to cumulative dosing), many are idiosyncratic and unpredictable.

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In this article:
Cytotoxic-induced lung damage
MCQ exam: clinical scenario
MCQ exam: answer
MCQ exam: explanation

Cytotoxic-induced lung damage

Bleomycin, busulphan, and methotrexate are by far the commonest cytotoxic drugs to cause interstitial pneumonitis. However, many other cytotoxic drugs have been reported to produce similar lung damage. Combined effects of these drugs, and of the drugs with other agents that cause lung damage, such as oxygen and radiation, may result in enhancement of lung damage. Early diagnosis, made possible by awareness of this complication and its correct investigation, may reduce severe morbidity and mortality.

MCQ exam: clinical scenario

Pulmonary abnormalities are a known side effect of several cytotoxic drugs.

Of the many cytotoxics, which of the following cytotoxic drugs is most likely to lead to a pleural friction rub?

a). Methotrexate
b). 5-fluorouracil
c). Taxoids
d). Cyclopentenyl cytosine
e). Trastuzumab

MCQ exam: answer

The correct answer is A.

MCQ exam: explanation

There are at least 40 drugs which may produce adverse pulmonary effects. The more common ones are bleomycin, busulfan, mitomycin, BCNU, arabinoside, IL2 and methotrexate. The clinical features that may be encountered are:

• dyspnoea,
• cough,
• pulmonary infiltrates,
• basal inspiratory crackles,

and, rarely, pleural friction rub, pleural effusions, pulmonary fibrosis and eosinophilia.

Reference(s)
1). C H Collis: Lung damage from cytotoxic drugs. Cancer Chemother Pharmacol. 1980;4(1):17-27. doi: 10.1007/BF00255453. Available online:
2). UpToDate: Pulmonary toxicity associated with antineoplastic therapy: Cytotoxic agents. Available online: https://www.uptodate.com/contents/pulmonary-toxicity-associated-with-antineoplastic-therapy-cytotoxic-agents