Recurrent Granulocyte Colony-Stimulating Factor-Induced Aortitis After Pegfilgrastim Administration

Granulocyte colony-stimulating factor (G-CSF) is used to prevent chemotherapy-associated febrile neutropenia. Oshima et al reported that 16 of 3,409 patients treated with G-CSF developed aortitis.¹

A 71-year-old woman was referred for fatigue and abnormal findings noted on contrast-enhanced computed tomography (CECT). After surgery for ovarian cancer, she received 5 cycles of chemotherapy with paclitaxel plus carboplatin. In addition, the patient received lenograstim and pegfilgrastim, 2 types of G-CSF, after the first cycle and after the second and fifth cycles of chemotherapy, respectively. CECT images obtained 6 months before referral showed no signs of aortitis (Figure A). After lenograstim injection, the patient was asymptomatic with normal blood test results. Three months before referral (i.e., 11 days after initial pegfilgrastim administration), CECT revealed double-ring enhancement in the descending thoracic aorta (Figure B). Two subsequent blood cultures were negative and the patient was treated with intravenous antibiotics for an infection of unknown origin. Her symptoms improved and the high C-reactive protein (CRP) level (34.14 mg/dL) normalized. Eleven days after the second pegfilgrastim administration, G-CSF-induced aortitis worsened (Figure C). The erythrocyte sedimentation rate (ESR) was >140 mm and the CRP level was 24.41 mg/dL. Clinical and laboratory parameters consistent with other vasculitides, including Takayasu and giant cell arteritis, were not detected. Without steroid use, follow-up computed tomography 27 days after the second pegfilgrastim injection showed improvement (Figure D), and the ESR and CRP levels gradually decreased.

Figure.

Contrast-enhanced computed tomography images. (A) Image obtained before the first administration of pegfilgrastim. (B) Double-ring enhancement in the descending thoracic aorta after the first injection of pegfilgrastim. (C) Double-ring enhancement was more apparent after the second injection of pegfilgrastim. (D) Improvement at the 27-day follow-up after the second injection of pegfilgrastim.

In a review of all 21 cases of G-CSF-induced aortitis reported thus far,² we found no cases of recurrent G-CSF-induced aortitis at the same site. G-CSF-induced aortitis needs to be considered before G-CSF is administered to patients.

Sources of Funding

This study was supported by scholarship funds from Otsuka Pharmaceutical Co., Ltd.

Disclosures

K.T. is a member of Circulation Reports’ Editorial Team. The other authors have no conflicts of interest to declare.

IRB Information

This study was approved by Shimane University Faculty of Medicine (No. 4658).

References

• 1.   Oshima Y, Takahashi S, Tani K, Tojo A. Granulocyte colony-stimulating factor-associated aortitis in the Japanese Adverse Drug Event Report database. Cytokine 2019; 119: 47–51.
• 2.   Shirai T, Komatsu H, Sato H, Fujii H, Ishii T, Harigae H. Migratory aortitis associated with granulocyte-colony-stimulating factor. Intern Med 2020; 59: 1559–1563.