A 46-year-old woman comes to the physician with complaints of exertional dyspnea over the last 6 months. She can barely walk a block without having to stop and catch her breath. She has minimal dry cough and denies chest pain, orthopnea, and hemoptysis. She reports intermittent lower-extremity swelling. The patient has lost 3 kg (7 lb) over the last 3 months due to poor appetite. She was diagnosed with Hodgkin's lymphoma 2 years ago and was treated with doxorubicin, bleomycin, vinblastine, and dacarbazine. She does not use tobacco, alcohol, or illicit drugs.
Her vital signs and physical examination are unremarkable. Laboratory studies, including complete blood count and lactate dehydrogenase, are normal. EKG shows normal sinus rhythm and no ST-segment or T-wave abnormalities.
Posteroanterior chest x-ray of the patient is shown below.

Which of the following conditions is the most likely cause of this patient's presentation?

Question

A 46-year-old woman comes to the physician with complaints of exertional dyspnea over the last 6 months.  She can barely walk a block without having to stop and catch her breath.  She has minimal dry cough and denies chest pain, orthopnea, and hemoptysis.  She reports intermittent lower-extremity swelling.  The patient has lost 3 kg (7 lb) over the last 3 months due to poor appetite.  She was diagnosed with Hodgkin's lymphoma 2 years ago and was treated with doxorubicin, bleomycin, vinblastine, and dacarbazine.  She does not use tobacco, alcohol, or illicit drugs.
Her vital signs and physical examination are unremarkable.  Laboratory studies, including complete blood count and lactate dehydrogenase, are normal.  EKG shows normal sinus rhythm and no ST-segment or T-wave abnormalities.
Posteroanterior chest x-ray of the patient is shown below.

Which of the following conditions is the most likely cause of this patient's presentation?

Quizplus · Accepted Answer

11ec193a_9837_bd6f_853d_85fee1c8127f_MD0002_00 This patient presents with exertional dyspnea, lower-extremity swelling, cardiomegaly, and a history of Hodgkin's lymphoma treated with anthracycline chemotherapy, all suggestive of doxorubicin-induced cardiomyopathy. Anthracyclines such as doxorubicin can cause acute/subacute or chronic cardiotoxicity. Acute toxicity is rare and occurs within weeks of treatment. Patients present with arrhythmias, heart block, pericarditis, and/or heart failure. However, patients with chronic toxicity usually present with heart failure symptoms within 1-2 years of treatment. Risk factors for the development of cardiotoxicity include cumulative dose, use of other cardiotoxic drugs, history of chest irradiation, pre-existing cardiovascular disease, and history of bone marrow transplantation. The risk of cardiotoxicity can be reduced by limiting the cumulative dose of anthracycline. Patients should also have left ventricular ejection fraction (LVEF) closely monitored during therapy. Treatment should be stopped when LVEF declines; cessation of therapy usually leads to return of LV function. Dexrazoxane (an EDTA-like chelator) is approved to decrease the severity of cardiomyopathy associated with anthracycline use in patients who have received a cumulative dose of 300 mg/m² and who will continue to receive anthracyclines. However, it is not recommended for use in patients who are initiating treatment as it lowers response to chemotherapy. ² (Choice B) Bleomycin can cause pulmonary fibrosis and, less commonly, organizing pneumonia and hypersensitivity pneumonitis. Physical examination reveals lung crackles and hypoxemia, and chest x-ray shows volume loss and/or nodular densities. (Choice C) This patient's chest x-ray does not show signs of pleural involvement (eg, thickening and effusion), and she does not complain of pleuritic chest pain. It is therefore unlikely that pleural disease is a cause of her exertional dyspnea. (Choice D) Recurrence of lymphoma is unlikely in a patient with no lymphadenopathy, cytopenias, tumor growth, or elevated levels of lactate dehydrogenase. (Choice E) The risk of developing a second malignancy is increased in survivors of Hodgkin's lymphoma, especially those who smoke, had the disease at a younger age (< 25 years), and received irradiation and certain chemotherapy (eg, alkylating agents). Second malignancies usually occur 5-10 years after treatment for lymphoma. This patient's symptoms are most consistent with doxorubicin-induced cardiotoxicity. Educational objective: Doxorubicin and other anthracyclines cause cardiotoxicity related to the cumulative dose of chemotherapy. Other risk factors for developing cardiotoxicity include exposure at an early age, pre-existing cardiovascular disease, concurrent use of other cardiotoxic agents, chest irradiation, and bone marrow transplantation. __________ References: Chemotherapy-induced cardiotoxicity. (http://www.ncbi.nlm.nih.gov/pubmed/22382639)

A 46-Year-Old Woman Comes to the Physician with Complaints of Exertional