Alemtuzumab
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Diffuse alveolar damage: case report A 42-year-old woman developed diffuse alveolar damage (DAD) during treatment with alemtuzumab for multiple sclerosis. The woman, who was diagnosed with multiple sclerosis in 2008, had previously been treated with multiple immunotherapies. Subsequently, she started receiving alemtuzumab 12mg daily [route not stated] over 5 days in January 2014, alongside multiple concomitant medications. However, 2 months later, she developed a progressive non-productive cough, accompanied by exertional dyspnoea and general exhaustion. During this time, her CRP levels and leucocyte count remained normal. CT scan of the lung revealed atelectasis in both lower lobes. No evidence of atypical pneumonia was detected. Lung function tests revealed respiratory alkalosis (pH7.46, pCO2 34.3mm Hg) and a high-grade restriction in diffusion capacity (diffusing capacity of the lung for carbon monoxide 45%), a low-grade restrictive lung disease (vital capacity 2.75L) without obstructive impairment (FEV1/VC: 88.7%) and a respiratory partial insufficiency (decrease of pO2 from 89mm Hg to 78mm Hg and increase of lactate from 1.0–5.5 mmol/L during exercise with 150 watt). Bronchoalveolar lavage revealed a reduced CD4/CD8-ratio and a moderately active inflammation, compatible with an extrinsic allergic alveolitis or a damage to pneumocytes resulting from drug toxicity. An extrinsic allergic alveolitis seemed unlikely in view of negative specific IgG antibodies. Prick test and Methacholin provocation tests were found to be negative. Transbronchial lung biopsy revealed hyperplasia of alveolar pneumocytes and remnants of hyaline membranes, compatible with a diffuse alveolar damage. There was no evidence of infection. Urine test, renal function and anti-GBM antibodies were unremarkable. Thyroid function and platelet counts were normal. Hence, she was diagnosed with diffuse alveolar damage secondary to alemtuzumab. The woman’s treatment with alemtuzumab was discontinued, and her respiratory symptoms regressed over the subsequent months. She did not receive corticosteroids. Diffusion capacity improved by December 2015. The results of lung function tests and blood gas analyses normalised. Thereafter, she started receiving off-label therapy with rituximab in January 2015. Bayas A, et al. Alemtuzumab-associated diffuse alveolar damage - a case report. BMC Neurology 20: No. 1, 23 Sep 2020. Available from: URL: http://doi.org/10.1186/ 803521130 s12883-020-01934-7
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Reactions 12 Dec 2020 No. 1834
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