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due to gastrointestinal intolerance&#46; In 2021&#44; she presented in the emergency department complaining of a one-month history of severe dyspnea &#40;mMRC 3&#41;&#44; dry cough and chest pain&#46; On auscultation&#44; there was a decrease in breath sounds on the right inferior lung field&#46; There were no other abnormalities on physical examination&#46;</p><p id="para0004" class="elsevierStylePara elsevierViewall">A chest radiograph revealed a small volume bilateral pleural effusion&#44; which was larger on the right&#46; A CT-Scan of the thorax was then performed showing a bilateral free-flowing pleural effusion&#44; which was larger on the right&#44; and a partial collapse of the right middle lobe with no clear obstructive cause&#46; A flexible bronchoscopy provided better characterization with the finding of right middle bronchus tapering&#44; allowing the progression of the bronchoscope&#46; A bronchoalveolar lavage and brushing were performed in that bronchial segment&#44; with no abnormalities found&#46; An ultrasound-guided diagnostic thoracocentesis was performed&#44; with the removal of 26 mL of pleural effusion with a hazy and milky appearance&#44; classified as a lymphocytic predominant exudate&#46; The pleural fluid was categorized as a chylothorax after the biochemical examination &#40;pleural fluid triglyceride concentration of 375 mg&#47;dL&#41;&#46; The pleural fluid culture&#44; immunophenotyping and cytology exam were negative&#46; Liver function tests were normal&#46;</p><p id="para0005" class="elsevierStylePara elsevierViewall">A clinical suspicion of a Bosutinib induced chylothorax was raised&#46; Since all the criteria for stopping TKI were met&#44; Bosutinib was withdrawn&#44; with a complete resolution of the bilateral pleural effusion within five weeks&#44; therefore confirming the diagnosis&#46; Respiratory symptoms resolved within a week&#46; The patient remains in complete molecular response after 6 months without TKI therapy&#46;</p><p id="para0006" class="elsevierStylePara elsevierViewall">Pulmonary toxicity is a common adverse effect of Dasatinib therapy&#44; particularly pleural effusion&#44; with a reported incidence as high as 39&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> Although the risk decreases over time&#44; it can occur throughout the whole treatment&#46; Bosutinib has also been associated with pleural effusion&#44; with a reported incidence around 5&#37; in the first-line setting and up to 17&#37; in later-line settings<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a>&#46; Known risk factors for Dasatinib-related pleural effusion include cardiac disease&#44; arterial hypertension&#44; pulmonary disease&#44; hypercholesterolemia&#44; autoimmune disease&#44; advance phase CML and age older than 60 years and are thought to be the same for Bosutinib&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a></p><p id="para0007" class="elsevierStylePara elsevierViewall">Management of Dasatinib-related pleural effusion is based on its estimated size on chest x-ray and the severity of symptoms&#46; Small&#44; asymptomatic pleural effusions &#40;&#60; 500 mL&#41; may only require close monitoring&#59; if symptomatic&#44; they can be managed with temporary TKI suspension and treatment can resume at the same or a lower dose&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> If the pleural effusion does not resolve with TKI suspension&#44; diuretics or a short course of corticosteroids are options in stable patients&#46; Severe pleural effusions which cause dyspnea may require thoracentesis&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> For recurrent pleural effusions&#44; switching to another TKI should be considered depending on severity&#44; so that CML treatment is not compromised with further dose reductions&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> There are no specific data regarding nutritional management of Dasatinib-related chylothorax&#44; however there is a rationale to include a medium-chain triglyceride diet as an add-on strategy for large recurrent chylothorax&#46; Similarly&#44; no specific recommendations exist for the management of Bosutinib-related pleural effusions&#44; but it seems reasonable to follow a similar strategy&#46;</p><p id="para0008" class="elsevierStylePara elsevierViewall">Although TKIs have revolutionized the treatment of patients with CML&#44; there are clinically important pulmonary toxicities to be aware of&#46; As far as we know&#44; this is the first report of a Bosutinib-associated chylothorax&#46; Other than older age&#44; the patient had none of the risk factors known to be associated with Dasatinib-related pleural effusion&#46; Therefore&#44; and due to this infrequent presentation&#44; a high clinical suspicion is required&#46;</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia><elsevierMultimedia ident="fig0002"></elsevierMultimedia><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0002">Patient consent</span><p id="para0009" class="elsevierStylePara elsevierViewall">Written informed consent was obtained from the patient for publication of her clinical details and images&#46;</p></span></span>"
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Letter to the Editor
Chylothorax as an unusual presentation of Bosutinib therapy toxicity
I. Farinhaa,?>*
Corresponding author
i.t.farinha@gmail.com

Corresponding author at:
, J. Gaião Santosb, A. Cunhaa, T. Costaa
a Pulmonology Department, Coimbra Hospital and University Centre, Coimbra, Portugal
b Haematology Department, Coimbra Hospital and University Centre, Coimbra, Portugal
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due to gastrointestinal intolerance&#46; In 2021&#44; she presented in the emergency department complaining of a one-month history of severe dyspnea &#40;mMRC 3&#41;&#44; dry cough and chest pain&#46; On auscultation&#44; there was a decrease in breath sounds on the right inferior lung field&#46; There were no other abnormalities on physical examination&#46;</p><p id="para0004" class="elsevierStylePara elsevierViewall">A chest radiograph revealed a small volume bilateral pleural effusion&#44; which was larger on the right&#46; A CT-Scan of the thorax was then performed showing a bilateral free-flowing pleural effusion&#44; which was larger on the right&#44; and a partial collapse of the right middle lobe with no clear obstructive cause&#46; A flexible bronchoscopy provided better characterization with the finding of right middle bronchus tapering&#44; allowing the progression of the bronchoscope&#46; A bronchoalveolar lavage and brushing were performed in that bronchial segment&#44; with no abnormalities found&#46; An ultrasound-guided diagnostic thoracocentesis was performed&#44; with the removal of 26 mL of pleural effusion with a hazy and milky appearance&#44; classified as a lymphocytic predominant exudate&#46; The pleural fluid was categorized as a chylothorax after the biochemical examination &#40;pleural fluid triglyceride concentration of 375 mg&#47;dL&#41;&#46; The pleural fluid culture&#44; immunophenotyping and cytology exam were negative&#46; Liver function tests were normal&#46;</p><p id="para0005" class="elsevierStylePara elsevierViewall">A clinical suspicion of a Bosutinib induced chylothorax was raised&#46; Since all the criteria for stopping TKI were met&#44; Bosutinib was withdrawn&#44; with a complete resolution of the bilateral pleural effusion within five weeks&#44; therefore confirming the diagnosis&#46; Respiratory symptoms resolved within a week&#46; The patient remains in complete molecular response after 6 months without TKI therapy&#46;</p><p id="para0006" class="elsevierStylePara elsevierViewall">Pulmonary toxicity is a common adverse effect of Dasatinib therapy&#44; particularly pleural effusion&#44; with a reported incidence as high as 39&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> Although the risk decreases over time&#44; it can occur throughout the whole treatment&#46; Bosutinib has also been associated with pleural effusion&#44; with a reported incidence around 5&#37; in the first-line setting and up to 17&#37; in later-line settings<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a>&#46; Known risk factors for Dasatinib-related pleural effusion include cardiac disease&#44; arterial hypertension&#44; pulmonary disease&#44; hypercholesterolemia&#44; autoimmune disease&#44; advance phase CML and age older than 60 years and are thought to be the same for Bosutinib&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a></p><p id="para0007" class="elsevierStylePara elsevierViewall">Management of Dasatinib-related pleural effusion is based on its estimated size on chest x-ray and the severity of symptoms&#46; Small&#44; asymptomatic pleural effusions &#40;&#60; 500 mL&#41; may only require close monitoring&#59; if symptomatic&#44; they can be managed with temporary TKI suspension and treatment can resume at the same or a lower dose&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> If the pleural effusion does not resolve with TKI suspension&#44; diuretics or a short course of corticosteroids are options in stable patients&#46; Severe pleural effusions which cause dyspnea may require thoracentesis&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> For recurrent pleural effusions&#44; switching to another TKI should be considered depending on severity&#44; so that CML treatment is not compromised with further dose reductions&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> There are no specific data regarding nutritional management of Dasatinib-related chylothorax&#44; however there is a rationale to include a medium-chain triglyceride diet as an add-on strategy for large recurrent chylothorax&#46; Similarly&#44; no specific recommendations exist for the management of Bosutinib-related pleural effusions&#44; but it seems reasonable to follow a similar strategy&#46;</p><p id="para0008" class="elsevierStylePara elsevierViewall">Although TKIs have revolutionized the treatment of patients with CML&#44; there are clinically important pulmonary toxicities to be aware of&#46; As far as we know&#44; this is the first report of a Bosutinib-associated chylothorax&#46; Other than older age&#44; the patient had none of the risk factors known to be associated with Dasatinib-related pleural effusion&#46; Therefore&#44; and due to this infrequent presentation&#44; a high clinical suspicion is required&#46;</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia><elsevierMultimedia ident="fig0002"></elsevierMultimedia><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0002">Patient consent</span><p id="para0009" class="elsevierStylePara elsevierViewall">Written informed consent was obtained from the patient for publication of her clinical details and images&#46;</p></span></span>"
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Article information
ISSN: 25310437
Original language: English
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