A 67-year-old woman with a history of hypertension, New York Heart Association (NYHA) grade II heart failure, and chronic atrial fibrillation.
In April 2004 the patient was diagnosed with stage IIIA (T3N1M0) ductal carcinoma of the left breast.
Mastectomy and left axillary lymphadenectomy were performed.
The pathology report was ductal carcinoma with 75 mm maximum diameter, 4 nodes affected by 9, hormone receptors negative and HER2 overexpression.
In the postoperative control, adenopathies were detected in the left supraclavicular fossa and the thoracic computerized tomography (CAT) also showed ipsilateral subpectoral and axillary lymphadenopathies.
In view of the contraindication for immobilisation in patients with underlying heart disease (left ventricular ejection fraction [LVEF] of 46%), and in the case of a tumour with HER2 overexpression, docetaxel was administered weekly
After the 10 week of treatment, the patient was admitted due to dyspnea with minimal effort of progressive onset, dry cough and chest pain.
Physical examination revealed tachypnea with normal respiratory auscultation, with no signs of heart failure or fever.
He also had severe onycholysis and epiphora.
The chest X-ray showed a diffuse bronchioloalveolar infiltrate of right predominance and left pleural effusion.
Laboratory tests showed mild hypoalbuminemia, the rest being anodyne.
The gas showed hypoxemia and hypocapnia (pO2 61, pCO2 31) and the electrocardiogram showed atrial fibrillation already known at 110 per minute.
The suspected presence of cardiac arrest secondary to trastuzumab treatment was repeated with an echocardiogram, which did not show a decrease in LVEF compared to baseline.
Chest CT showed right broccoalveolar infiltrate with bilateral pleural effusion and moderate pericardial effusion.
On the other hand, complete remission of axillary, subpectoral and supraclavicular lymph nodes was observed.
Bronchoscopy and cystoscopy were performed to rule out progression of the disease or opportunistic infection.
Microbiological and cytological analysis of bronchial samples and pleural fluid was negative.
Bronchoalveolar lavage revealed hyperreactive bronchioloalveolar cells suggestive of cell damage.
Given the negativity of all the examinations performed, the case was referred as a possible pulmonary toxicity for trastuzumab and glucocorticoid treatment was started at a dose of 1 mg/kg of weight with rapid resolution of the respiratory clinical infiltrate.
The patient required suspension of cytological treatment and received radiotherapy on the chest wall, axillary and supraclavicular regions to consolidate the response.
