Hydroxychloroquine/tacrolimus

Author Information

An event is serious (FDA MedWatch definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * requires intervention to prevent permanent impairment or damage

A 44-year-old woman developed peripheral T-cell lymphoma unspecified and acute hypoxaemic respiratory failure following treatment with hydroxychloroquine and tacrolimus [routes, dosages and time to reactions onsets not stated].

The woman had antisynthetase syndrome (ASS) and rheumatoid arthritis since 18 years which was complicated by nonspecific interstitial pneumonitis since 5 years. She was started on hydroxychloroquine and tacrolimus ASS. Her initial BP was 149/59mm Hg, RR was 26/minute, body temperature was 38.2°C, HR was 103 /minute and pulse oximetry was 79% on room air. She had coarse bi-basilar crackles and was in mild to moderate respiratory distress. New diffuse bilateral patchy alveolar and interstitial opacities were revealed by chest radiography. Her platelet count was 2 68 000, haemoglobin was 12.2 g/dL, WBC was 24 500 /mm³ (54% lymphocytes and 38% neutrophils), blood urea nitrogen was 26, creatinine was 1.01 mg/dL and potassium was 5.0 mEq/L. Initial differential diagnoses comprised of an acute exacerbation of interstitial lung and the adult respiratory distress syndrome (ARDS) from infection. She was supported with high-flow oxygen via nasal cannula after being admitted to the ICU. She was empirically on antimicrobials targeting health care-associated infectious pneumonia-induced ARDS, but she failed to improve. A bilateral patchy consolidation and multiple enlarged axillary and mediastinal lymph nodes were revealed by a chest CT on hospital day 2. Her hypoxaemia and clinical condition continued to decline requiring an endotracheal intubation on hospital day 3. On hospital day 5, video-assisted thoracoscopic biopsies from the right middle and lower lobes revealed peripheral T-cell lymphoma, not otherwise specified. Staging evaluation showed stage 4 disease.

The woman was commenced on a chemotherapeutic regimen of vincristine, cyclophosphamide, doxorubicin and prednisone on hospital day 10. An interval improvement in pulmonary infiltrates and patchy consolidation was revealed by a chest CT. On hospital day 13, she was extubated. She was discharged on hospital day 28 with 3 L/minute O₂. She showed complete resolution of hypoxaemic respiratory failure

Author comment: "Proposed mechanisms for this association includes dysregulated immunity and chronic immunosuppression in RA, which disables the immune system from surveying and suppressing neoplastic lymphoid cell line and virus growth." "Our case highlights 2 rare and important findings. First, our case highlights malignancy in the setting of ASS. Second, it highlights the presentation of PTCL-NOS as an acute hypoxemic respiratory failure in a patient with ASS."