Lenalidomide-induced High Grade Fever in A Patient With Multiple Myeloma: A Case Report - Lenalidomide-induced High Grade Fever in A Patient With Multiple Myeloma: A Case Report - Open Access Pub

Lenalidomide is a second generation immunomodulatory agent and a potent analogue of thalidomide that is FDA approved mainly for the treatment of multiple myeloma (MM) and transfusion-dependent anemia due to low or intermediate-1- risk myelodysplastic syndromes (MDS) associated with 5q deletion among other indications. Through its action on the immune system, lenalidomide alters the production of different cytokines ultimately resulting in immune activation against tumors. This immune activation may lead to collateral immune toxicities like fever, angioedema, Stevens-Johnson syndrome, tumor flare and others. Here we report a case of lenalidomide-induced high grade fever in a patient with MM and we summarize the literature about the physiology of such reaction and how to mitigate this adverse event. DOI10.14302/issn.2641-5518.jcci-19-2664 A 59 year-old-woman with newly diagnosed IgG kappa MM presented to the emergency department with fever and generalized body aches one day after starting her first cycle of therapy with lenalidomide, bortezomib and dexamethasone. She denied any shortness of breath, cough, runny nose, dysuria, diarrhea, abdominal pain, and headache or neck stiffness. Physical examination was unremarkable except for fever (temperature of 39° C) and tachycardia. Patient was started on broad spectrum antibiotics and admitted for workup. Infectious workup included repeated blood and urine cultures, chest x-ray, nasal swab for viruses and all were negative. Her complete blood count and differential was within normal limits. Patient remained febrile for 5 days (Figure 1), despite escalating and changing her antimicrobial therapy. After six days of hospitalization, antibiotics and lenalidomide were discontinued. Fever subsided within few hours and patient was then discharged in stable condition. The patient was then treated with cyclophosphamide, bortezomib and dexamethasone and underwent autologous hematopoietic cell transplant after achieving a very good partial remission. The patient refused maintenance therapy post-transplant and relapsed 2 years after transplant. Upon relapse, patient was treated with low dose lenalidomide (10 mg daily), bortezomib and dexamethasone and tolerated this regimen well and later on lenalidomide dose was escalated to the standard dose of 25 mg daily Figure 1. Pattern of temperature during lenalidomide uprake Lenalidomide is a 4-amino-glutamyl analogue of thalidomide, modified in a way to minimize the neurologic side effects and to improve the efficacy of thalidomide. It is a second generation immunomodulatory