Everolimus-induced interstitial pneumonitis in a kidney transplant recipients: A case report

Abstract

Use of serin-threonine kinase inhibitors, sirolimus and everoli- mus are recommended to decrease the potential development of chronic allograft nephropathy during chronic phase in renal transplant patients. Although these drugs have serious side ef- fects such as proteinuria, edema, hyperlipidemia, impaired wo- und healing, mouth ulcers, anemia and proteinuria, among them the most important one is interstitial pneumonitis which is fre- quently related to sirolimus use. Hovewer, in the literature a few cases of everolimus-induced interstitial pneumonitis (EIP) have been reported recently. We wanted to revive this issue with this caase presentation under the light of current information.A 48- year-old man was admitted with complaints of cough, fever and bloody sputum. He had living-donor kidney transplantation from his spouse 15 months ago. The etiology of end-stage renal disease was amyloidosis due to familial Mediterrenean fever. On physical examination, he had fever ( 38°C), and bilateral basal fine crackles were detected. Everolimus was started 5 months ago because of the calcineurin inhibitor toxicity. He has also been on azathioprin, methylprednisolone and colchicine therapy. His remarkable labo- ratory findings were as follows: Hg: 7.8 g/dl, C-reactive protein:4.5 mg/l, and creatinine: 2.8 mg/dl. Everolimus blood trough levelwas 4.2 ng/ml.I On chest X-ray, bilateral interstitial infiltrates, re- ticular images and alveolar opacities were observed especially in the mid and lower zones. High-resolution pulmonary computed- tomography revealed centri-acinar nodules with patchy areas of ground glass opacities in posterobasal segments of the both lungs being more pronounced in the right lower lobe, interlobar septal thickening and reticular lines in the adjacent pleural sur- faces. Cultures of blood, urine, sputum and blood, were negative for cytomegalovirus and mycobacterium PCR. Hemosiderin laden macrophages were observed in his bronchoalveolar lavage. Then symptoms and signs of the patient were suggestively related to everolimus, and this drug was discontinued. Contrary to previous assumptions, everolimus can induce development of interstitial pneumonia, and alveolar hemorrhagia. Because of higher rates of mortality associated with this condition, the patients should be diagnosed, and treated at an early stage. This side effect of the drug should be kept in mind.