Eflapegrastim-induced large vessel vasculitis in patient treated with recurrent uterine leiomyosarcoma

Background: Granulocyte colony-stimulating factor (G-CSF) is widely used to prevent febrile neutropenia during chemotherapy. However, it can rarely induce large-vessel vasculitis (LVV), a condition that is challenging to recognize early and may lead to serious complications. Case: A 66-year-old woman with recurrent uterine leiomyosarcoma received long-acting G-CSF (eflapegrastim) for prophylaxis against neutropenia after initial systemic chemotherapy. Ten days after the first administration of eflapegrastim, she developed fever and fatigue. Contrast-enhanced computed tomography (CT) revealed new circumferential wall thickening of the aortic arch, proximal descending thoracic aorta, left proximal common carotid artery, and proximal subclavian artery. Positron emission tomography (PET) subsequently demonstrated increased fluorodeoxyglucose uptake, supporting a diagnosis of acute vasculitis. Corticosteroid therapy was promptly initiated after multidisciplinary discussion, resulting in rapid symptomatic improvement within 2 weeks and complete radiologic resolution after 4 weeks. Conclusion: Acute LVV induced by long-acting G-CSF is an emerging adverse event with potentially life-threatening consequences. Early suspicion and prompt use of imaging modalities, such as CT and PET, are essential for accurate diagnosis, enabling timely corticosteroid therapy and improved clinical outcomes.

Granulocyte-colony stimulating factor; Eflapegrastim; Large-vessel vasculitis; Workup

[1] Klastersky J, de Naurois J, Rolston K, Rapoport B, Maschmeyer G, Aapro M, et al. Management of febrile neutropaenia: ESMO clinical practice guidelines. Annals of Oncology. 2016; 27: v111–v118.

[2] Fitzhugh CD, Hsieh MM, Bolan CD, Saenz C, Tisdale JF. Granulocyte colony-stimulating factor (G-CSF) administration in individuals with sickle cell disease: time for a moratorium? Cytotherapy. 2009; 11: 464–471.

[3] D’Souza A, Jaiyesimi I, Trainor L, Venuturumili P. Granulocyte colony-stimulating factor administration: adverse events. Transfusion Medicine Reviews. 2008; 22: 280–290.

[4] Marlecha P, Kapadia S, Rosenzveig A, Wolff R, Nanjundappa A. Pegfilgrastim (Neulasta)-induced acute aortitis: a case report.European Heart Journal—Case Reports. 2025; 9: ytaf513.

[5] Costa Silva R, Monteiro M, Dias RP, Silva I, Rodrigues Dos Santos J, Vassalo T, et al. Large-vessel vasculitis induced by pegfilgrastim. Acta Reumatologica Portuguesa. 2021; 46: 355–359.

[6] Jimbo H, Horimoto Y, Okazaki M, Ishizuka Y, Kido H, Saito M. Drug-induced aortitis of the subclavian artery caused by pegfilgrastim: a case report. Surgical Case Reports. 2021; 7: 197.

[7] Saito H, Suda T, Oishi N, Matsushita E. Pegfilgrastim-induced large vessel vasculitis. BMJ Case Reports. 2021; 14: e243757.

[8] Seto Y, Kittaka N, Taniguchi A, Kanaoka H, Nakajima S, Oyama Y, et al. Pegfilgrastim-induced vasculitis of the subclavian and basilar artery complicated by subarachnoid hemorrhage in a breast cancer patient: a case report and review of the literature. Surgical Case Reports. 2022; 8: 155.

[9] Sato Y, Kaji S, Ueda H, Tomii K. Thoracic aortitis and aortic dissection following pegfilgrastim administration. European Journal of Cardio-Thoracic Surgery. 2017; 52: 993–994.

[10] Lee SY, Kim EK, Kim JY, Park TK, Choi SH, Im YH, et al. The incidence and clinical features of PEGylated filgrastim-induced acute aortitis in patients with breast cancer. Scientific Reports. 2020; 10: 18647.

[11] Sasaki K, Miyauchi M, Ogura M, Shimura-Nukina A, Toyama K, Nakazaki K, et al. Arteritis after administration of granulocyte colony-stimulating factor: a case series. International Journal of Hematology. 2019; 110: 370–374.

[12] Takamatsu A, Yoshida K, Toshima F, Kozaka K, Yamamoto N, Sai Y, et al. Single-center analysis of pegfilgrastim-induced aortitis using a drug prescription database and CT findings. Radiology. 2022; 305: 729–740.

[13] Jennette JC, Falk RJ, Bacon PA, Basu N, Cid MC, Ferrario F, et al. 2012 revised international Chapel Hill consensus conference nomenclature of vasculitides. Arthritis & Rheumatism. 2013; 65: 1–11.

[14] Loricera J, Calvo-Rio V, Ortiz-Sanjuan F, Gonzalez-Lopez MA, Fernandez-Llaca H, Rueda-Gotor J, et al. The spectrum of paraneoplastic cutaneous vasculitis in a defined population: incidence and clinical features. Medicine. 2013; 92: 331–343.

[15] Sugai Y, Toyoguchi Y, Kanoto M, Kirii K, Hiraka T, Konno Y, et al. Clinical and image features: large-vessel vasculitis after granulocyte colony stimulating factor administration. Acta Radiologica. 2024; 65: 383–391.

[16] Miller EB, Grosu R, Landau Z. Isolated abdominal aortitis following administration of granulocyte colony stimulating factor (G-CSF). Clinical Rheumatology. 2016; 35: 1655–1657.

[17] Hoshina H, Takei H. Granulocyte-colony stimulating factor-associated aortitis in cancer: a systematic literature review. Cancer Treatment and Research Communications. 2021; 29: 100454.

[18] Cook AD, Pobjoy J, Sarros S, Steidl S, Durr M, Lacey DC, et al. Granulocyte-macrophage colony-stimulating factor is a key mediator in inflammatory and arthritic pain. Annals of the Rheumatic Diseases. 2013; 72: 265–270.

[19] Taimen K, Heino S, Kohonen I, Relas H, Huovinen R, Hanninen A, et al. Granulocyte colony-stimulating factor- and chemotherapy-induced large-vessel vasculitis: six patient cases and a systematic literature review. Rheumatology Advances in Practice. 2020; 4: rkaa004.

[20] Zhao T, Xu H. Literature review analysis of aortitis induced by granulocyte-colony stimulating factor. Frontiers in Pharmacology. 2024; 15: 1487501.