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Exacerbation of interstitial lung disease and lung toxicity: case report A 61-year-old man developed an exacerbation of interstitial lung disease and lung toxicity during treatment with carboplatin, pembrolizumab and pemetrexed for metastatic non-small cell lung cancer [routes and durations of treatments to reactions onsets not stated]. The man, who had diabetes mellitus, presented the lung cancer evaluation clinic due to abnormal CT scan. Initially, he had presented to his primary care physician with symptoms consistent with upper respiratory tract infection. His initial investigation was significant for pneumonia, and he was treated with a full course of unspecified antibacterials [antibiotics]. Follow-up chest CT scan showed a dominant mass in the superior segment of the right lower lobe along with bulky hilar and mediastinal adenopathy, as well as a pathologic fracture of the left fourth rib. Mild to moderate peripheral interstitial fibrotic change were also observed. However, he was not formally diagnosed with interstitial lung disease. Additionally, large right adrenal metastasis and metastases in the left frontal and parietal lobes with vasogenic oedema were observed. He started receiving prophylactic treatment with dexamethasone. After further investigations, a diagnosis of poorly differentiated adenocarcinoma (non-small cell lung cancer) was confirmed. Thus, he underwent stereotactic radiosurgery and stereotactic body radiation therapy. Subsequently, he started chemo-immunotherapy with pembrolizumab 200mg and carboplatin (area under the concentration–time curve, 5mg/mL/minute) along with pemetrexed 500mg per square meter every 3 weeks. He received folic acid and cobalamin [vitamin B12] supplementation prior to the initiation of treatment. CT scans of the chest, pelvis and abdomen after 2 cycles showed a mixed response with decrease in size of both the right lower lobe and right adrenal masses; however, a new hypodense lesion in the spleen was noted. Underlying fibrotic changes of the lungs were observed, and it raised concern for nonspecific interstitial pneumonia. Due to his asymptomatic condition treatment was continued. Two days prior to his fourth cycle, he presented to the emergency department with acute shortness of breath and pleuritic chest pain. He was noted to be tachycardic and tachypneic with significant hypoxia. Angiogram of the chest revealed severe progression of the previously described fibrotic changes with subpleural reticulations, ground glass opacities, severe honeycombing, mosaic attenuation and diffuse traction bronchiectasis with extensive multi-cystic ground glass opacities. Then, he was admitted to the ICU for acute hypoxic respiratory failure. The man received high-flow nasal cannula, unspecified empiric broad spectrum antibacterials and unspecified steroids. He tested positive for rhinovirus/enterovirus infection. He developed non ST segment elevation myocardial infarction and congestive heart failure exacerbation, which were managed conservatively. He was continued on the h