Stage IV lung adenocarcinoma with brain metastasis: partial remission after pemetrexed/cisplatin and AOSD-like paraneoplastic syndrome

What happened, in summary

This 56-year-old nonsmoking Chinese man was diagnosed in September 2010 with lung adenocarcinoma of the left lower lobe and cerebral metastasis after 2 months of cough and hemoptysis. He first received paclitaxel 135 mg/m² plus carboplatin AUC 6 on September 15, 2010. About 2 weeks later, he developed sore throat, fever, and then spiking fevers with joint pain in the knees and shoulders. Antibiotics did not help, and no infection was found in blood, sputum, throat, or urine cultures. During hospitalization, he developed an evanescent maculopapular rash, leukocytosis, thrombocytopenia, abnormal liver function tests, and markedly elevated ferritin of 2,000 ng/mL. Rheumatoid factor and antinuclear antibodies were negative. Imaging did not show a new infectious or inflammatory source beyond the known lung and brain tumors. A steroid injection briefly lowered the fever, but it returned. The pattern suggested adult-onset Still disease-like paraneoplastic syndrome. Oral nimesulide 100 mg every 12 hours was started, and his temperature normalized over 5 days with improvement in other symptoms and liver tests. His performance status improved enough to resume chemotherapy, but the regimen was changed to pemetrexed 500 mg/m² plus cisplatin 75 mg/m² on October 29, 2010. After 2 cycles, CT showed significant reduction of the lung mass and ferritin fell. Four more cycles were given every 21 days with good tolerance. As of November 2011, he achieved partial remission and had no recurrent AOSD-like manifestations. The improvement of fever, ferritin, liver tests, and tumor burden supported the paraneoplastic nature of the inflammatory syndrome.