Hypersensitivity Pneumonitis-Like Drug-Induced Interstitial Lung Disease Caused by Pegylated Liposomal Doxorubicin: A Case Report

Drug-induced interstitial lung disease (DI-ILD) encompasses a wide spectrum of imaging and histopathologic patterns, sometimes resembling hypersensitivity pneumonitis (HP). Pegylated liposomal doxorubicin (PLD, Doxil®) is a nanoparticulate formulation of doxorubicin designed to reduce systemic toxicity, and pulmonary toxicity is rarely documented. We report a 62-year-old woman with recurrent ovarian carcinoma who developed fever and erythema after the third cycle of PLD, followed by diffuse pulmonary infiltrates. She had no history of allergy, lung disease, or environmental antigen exposure. On admission, chest radiography revealed bilateral fine granular opacities, and high-resolution computed tomography demonstrated diffuse centrilobular ground-glass nodules predominantly in the upper lobes. Bronchoalveolar lavage showed marked lymphocytosis with elevated total cell counts, and transbronchial lung biopsy revealed noncaseating epithelioid granulomas with lymphocytic infiltration, consistent with an HP-like pattern. Microbiologic and autoimmune evaluations were negative. Based on the temporal association with PLD administration, compatible imaging and histopathologic findings, and exclusion of other etiologies, a diagnosis of HP-like DI-ILD induced by PLD was made. Prednisolone 50 mg daily led to rapid defervescence and remarkable radiologic improvement within two weeks, followed by complete remission after tapering and no recurrence during 4.5 months of follow-up until death from progressive ovarian cancer. This case highlights that PLD, though considered relatively safe, can induce HP-like DI-ILD, and prompt recognition with appropriate corticosteroid therapy may achieve favorable outcomes. Clinicians should remain vigilant for this rare but potentially severe pulmonary toxicity.