YO20 - A case of drug-induced large vessel vasculitis with hoarseness as the chief complaint caused by pegfilgrastim during chemotherapy

Case summary

Background
Prophylactic administration of pegfilgrastim (pegylated granulocyte colony-stimulating factor: PEG-G-CSF) is recommended for patients at high risk of febrile neutropenia (FN) during chemotherapy. However, rare cases of large-vessel vasculitis (LVV) after G-CSF administration have been reported. In this report, we describe a case of LVV with hoarseness as the chief complaint caused by PEG-G-CSF.

Case summary
A 73-year-old woman was started on postoperative adjuvant chemotherapy for breast cancer and received PEG-G-CSF for primary prevention of FN. Nine days after receiving PEG-G-CSF, the patient visited us with hoarseness as the chief complaint. Since her white blood cell (WBC) count was high, FN was ruled out and she was diagnosed with pharyngitis.
However, when she revisited us two days later, she had a fever, elevated WBC and C-reactive protein, and was hospitalized. Non-enhanced computed tomography (CT) scan revealed a suspected case of superior mediastinitis, and antimicrobial agents were started. Considering the lack of improvement in blood tests, negative blood cultures and resistance to antimicrobial agents, drug-induced inflammation was suggested as a differential diagnosis. Enhanced CT revealed wall thickening of the bilateral subclavian arteries, leading to the diagnosis of drug-induced LVV caused by PEG-G-CSF.
Then, the hoarseness, the fever, and the inflammatory response spontaneously resolved over time without the use of steroids. Enhanced CT on Day 14 of admission showed improvement in the wall thickening of the bilateral subclavian arteries, and the patient was discharged. PEG-G-CSF was discontinued and the vasculitis had not been flared up.

Discussion
In similar reports to date, no cases with hoarseness have been found. The hoarseness in this case was thought to be transient recurrent nerve palsy caused by inflammation near the large vessels.
When hoarseness is observed during chemotherapy, LVV as well as infection should be considered.
An association with human leukocyte antigen (HLA) haplotypes is suspected as a genetic predisposition. In this case, HLA-B39, which is found in Takayasu's arteritis and ankylosing spondylitis, was detected.

Clinical trial identification

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