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INTRODUCTION: Antineoplastic agent-induced interstitial pneumonitis is a potentially lethal adverse event for which glucocorticoids are a treatment option although no studies have been conducted that demonstrate benefit. We describe a patient who developed delayed and lethal trastuzumab-related interstitial pneumonitis. CASE PRESENTATION:A 71-year-old female with Stage IIA invasive lobular carcinoma breast cancer (cT2N0; estrogen, progesterone and HER-2/neu positive) was treated with six courses of docetaxel, carboplatin, pertuzumab and trastuzumab without complication. She was then started on trastuzumab monotherapy and three weeks later, she developed acute hypoxemic respiratory failure with ARDS. Trastuzumab was stopped with no improvement. She was empirically treated with broad-spectrum antibiotics (including empiric Pneumocystis treatment) and antifungal, as she was too unstable for safe bronchoscopy. Having no improvement, she was treated with pulse steroids but failed to respond and died five weeks after presenting with ARDS. Autopsy showed diffuse alveolar damage and organizing pneumonia with negative cultures.

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Hematologic and oncologic disorders pose unique challenges, particularly in the setting of chronic disease. Many of the pathological states in this chapter are seen in subspecialized practice settings but are required knowledge universally because of the frequency of such patients suddenly deteriorating as disease and age progress. The rise of novel oral anticoagulants and their reversal agents adds to the complexity of this topic. The surgical population in particular requires the application of this knowledge set for safe patient care. As result, coagulopathy is definitively in the wheelhouse of every perioperative physician and can be expected to have daily application in practice.