Sunder, a young male was diagnosed as sufering from acute myeloid leukemia. He was staed on induction chemotherapy with dosorubicin based regiments. Induction regimen was successful. Two months later, he presents to OPD with swelling of both the feet and breathlessness on climbing the stairs. He also complains the he had to wake up many times because of breathlessness. Which of the following is most likely responsible for this patient’s symptoms?

## **Core Concept**
The patient's symptoms of swelling in both feet and breathlessness, particularly on exertion and at night, suggest congestive heart failure. This condition arises when the heart is unable to pump blood efficiently, leading to fluid buildup in the lungs and peripheral tissues. **Anthracyclines**, such as doxorubicin, are well-known chemotherapeutic agents that can cause cardiotoxicity.

## **Why the Correct Answer is Right**
Doxorubicin works by intercalating DNA strands, thereby inhibiting the synthesis of macromolecules and inducing apoptosis in cancer cells. However, one of its significant side effects is **cardiotoxicity**, leading to **dilated cardiomyopathy** and congestive heart failure. This cardiotoxicity is dose-dependent and can occur acutely or chronically after administration. The mechanism involves the generation of free radicals, which damage cardiac myocytes, and disruption of iron homeostasis, leading to cellular injury.

## **Why Each Wrong Option is Incorrect**
- **Option A:** While certain chemotherapeutic agents and radiation can cause pulmonary toxicity leading to symptoms like breathlessness, the presentation here, particularly with swelling of the feet, points more towards a cardiac cause.
- **Option B:** Although fluid overload can cause similar symptoms, the context provided (recent chemotherapy) and the specific symptoms suggest a cardiogenic cause rather than a simple fluid overload.
- **Option C:** Anemia could cause fatigue and shortness of breath but would not typically cause swelling in the feet.

## **Clinical Pearl / High-Yield Fact**
A key point to remember is that **doxorubicin-induced cardiotoxicity** can be dose-dependent, and monitoring of cardiac function (e.g., through echocardiography) is crucial in patients receiving cumulative doses over 300 mg/m^2. The use of **dexrazoxane**, a cardioprotective agent, can be considered in patients receiving anthracyclines to mitigate this risk.

## **Correct Answer:** . **Doxorubicin**

✓ Correct Answer: C. Dilated cardiomyopathy