Spontaneous Pneumomediastinum and Bilateral Pneumothoraces in a Patient with Bleomycin-Induced Pneumonitis

Bleomycin lung toxicity is well established and can manifest as bleomycin-induced pneumonitis, but pneumomediastinum and pneumothorax are very rare complications. We report the case of a 73-year-old woman, recently treated with bleomycin for Hodgkin’s disease, who was admitted for bleomycin-induced pneumonitis. Two weeks later she had a pneumomediastinum with extensive subcutaneous emphysema and small bilateral pneumothoraces. Three months after that she was readmitted for dyspnoea. The CT scan showed complete regression of the pneumomediastinum but extensive bilateral ground-glass infiltrates. The patient died from respiratory failure 2 weeks later. LEARNING POINTS: Respiratory investigation before initiation of bleomycin treatment and then close follow-up during treatment of any abnormalities found is mandatory, as bleomycin -induced toxicity can lead to fibrosis and secondary pneumothorax/pneumomediastinum with high morbidity/mortality. Bleomycin-induce pneumonitis (BIP) is managed with bleomycin discontinuation (Grade 1A) and system corticosteroid (Grade 1B). Supplemental oxygen is discouraged for BIP, but indicated for conservative management of pneumothoraces, so this case was managed with limited oxygen supplementation (aiming for oxygen saturation of 92–94%).