What causes runny eyes and nose in patients undergoing chemotherapy?

Runny Eyes and Nose During Chemotherapy

Runny eyes and nose during chemotherapy are most commonly caused by infusion reactions (hypersensitivity reactions) to specific chemotherapeutic agents, particularly taxanes and platinum compounds, though they can also result from direct ocular toxicity or rhinitis associated with certain drugs.

Primary Mechanism: Infusion Reactions

The most likely cause of concurrent runny eyes (lacrimation) and runny nose (rhinorrhea) during chemotherapy is an infusion-related hypersensitivity reaction, which represents an acute immune or pseudo-allergic response to the chemotherapeutic agent 1.

Key Features of Infusion Reactions:

• Timing: These reactions typically occur within minutes to hours of drug administration, most commonly during the first infusion 1
• Associated symptoms: Beyond rhinorrhea and lacrimation, patients may experience:
  • Flushing, pruritus, and rash 1, 2
  • Dyspnea and bronchospasm 1, 2
  • Chest pain, tachycardia, or hypotension 1
  • Fever and chills 1, 3

High-Risk Chemotherapy Agents:

Taxanes (paclitaxel, docetaxel) and platinum compounds (carboplatin, cisplatin) are the most frequent culprits for hypersensitivity reactions causing these symptoms 1, 2. Other agents with significant incidence include:

• Anthracyclines (particularly PEGylated liposomal doxorubicin): 7-11% incidence of infusion reactions 1
• Asparaginase: 60% hypersensitivity reactions overall 1
• Carboplatin: 12% incidence, with risk increasing after cumulative doses (highest around 8th course) 1

Secondary Causes

Direct Ocular Toxicity:

Some chemotherapeutic agents cause direct oculo-visual toxicity that can manifest as excessive tearing and ocular irritation 4. This mechanism is distinct from infusion reactions and may present as:

• Dry eyes paradoxically causing reflex tearing 4
• Photophobia and blurred vision 4
• Conjunctivitis or keratitis leading to lacrimation 4

Drug-Induced Rhinitis:

Certain chemotherapy agents can trigger inflammatory responses in the nasal mucosa through:

• Activation of inflammatory mediators and cytokine release 5
• Non-immune mediated histamine release 2
• Direct mucosal irritation 5

Clinical Approach

Immediate Assessment:

When a patient develops runny eyes and nose during chemotherapy infusion:

1. Stop or slow the infusion immediately 1

2. Assess for other signs of hypersensitivity:

   • Check vital signs (blood pressure, heart rate, oxygen saturation) 1
   • Examine for urticaria, angioedema, or respiratory distress 1, 2
   • Grade severity using CTCAE criteria 1

3. Administer symptomatic treatment based on severity:

   • Grade 1-2 reactions: Antihistamines (H1 and H2 blockers) and slow infusion rate 1
   • Grade 3-4 reactions: Stop treatment, give corticosteroids, antihistamines, and aggressive supportive care 1

Management Strategy:

For confirmed infusion reactions:

• After symptom resolution, rechallenge with reduced infusion rate and additional premedication (corticosteroids and antihistamines) 1
• Do not attempt rechallenge if the reaction was CTCAE grade 3 or higher or true anaphylaxis 1
• Consider desensitization protocols for platinum compounds if continued treatment is essential 1

For isolated ocular/nasal symptoms without systemic signs:

• Continue monitoring but may proceed with caution 4
• Consider symptomatic treatment with artificial tears or nasal saline 4
• Document the reaction for future reference 1

Important Caveats:

• Timing matters: Symptoms occurring on posttreatment days 3-4 are more likely drug fever or delayed reactions rather than acute infusion reactions 3
• First cycle risk: Fever and reactions occur more commonly in first cycles (41%) versus later cycles (30%) 3
• Excipient reactions: Some reactions may be due to drug vehicles (like Cremophor EL in paclitaxel) rather than the chemotherapy agent itself 2
• Documentation is critical: Always document the specific agent, timing, symptoms, and management for future treatment planning 1