Adverse Effects Of Chemotherapy And Rheumatic Symptoms

A number of antineoplastic agents are known to have adverse effects that might mimic a rheumatic disease. For example, Raynaud's phenomenon is well described in association with cisplatin, vinblastine and bleomycin [10], and more recently 5-fluorouracil may cause digital ischaemia [11], Furthermore, bleomycin is also associated with the development of scleroderma [12, 13]. The cutaneous lesions seen in these patients treated with bleomycin are indistinguishable from idiopathic scleroderma where lesional fibroblasts synthesize large amounts of collagen and gly-cosaminoglycan [13]. In the patients reported by Kerr and Spiera [12], the ANA was positive and they also noted some resolution of symptoms after stopping bleomycin and the addition of corticosteroids. Bleomycin in doses of 400 mgs or more may also result in pulmonary fibrosis, a well recognized feature of scleroderma [14]. The mechanism whereby bleomycin can induce a scleroderma like illness remains unknown but vascular injury is likely to be important. For example, endothelial cell injury is seen as an early lesion in experimental animal models of bleomycin induced pulmonary fibrosis [15].

Tamoxifen is widely used in the therapy of breast cancer patients and may be associated with rheumatic symptoms. For example, in Warner et al.'s [9] report, 9 out of the 23 patients developed rheumatic symptoms shortly after starting tamoxifen. Furthermore, 3 patients developed an inflammatory symmetrical polyarthritis between 2 weeks and 1 year of commencing tamoxifen which resolved on tamoxifen withdrawal [16]. The mechanism by which tamoxifen may induce rheumatic symptoms is unclear but could be related to its antioestrogenic effects. However, against this argument is that raloxifene, a newly licensed selective oestrogen receptor modulator for postmenopausal women, has not so far been associated with these symptoms [17].

Many combination chemotherapy regimens include corticosteroids, often in high doses and osteoporotic vertebral and hip fractures may occur which may be mistaken for pathological fractures from metastatic deposits. Similarly, steroid induced myopathies may initially be mistaken for inflammatory myopathies which may also occur with malignancies.

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