Abstract Checkpoint inhibitors (ICI) remain standard therapy for a variety of cancers. However, excessive immune responses can lead to immune-related adverse events in any organ system mainly through T-cell activation. Lung injury with checkpoint inhibitors has a low incidence, and serious life-threatening adverse effects such as DAH are rarer 1. A 75-year-old woman with a history of emphysema, coronary artery disease with prior bypass, polycythemia vera, multiple myeloma who was diagnosed with Stage IV non-small cell lung cancer presented to the hospital with dyspnea approximately ten days after her last chemotherapy. At baseline, she required 3L of supplemental oxygen in the setting of bilateral malignant pleural effusions. She was undergoing treatment with Pembrolizumab, carboplatin, and docetaxel. CT angiogram of the chest showed no evidence of pulmonary embolism though showed increased interstitial thickening and mosaic attenuation bilaterally with redemonstrated mass in the lingula. Empiric broad-spectrum antibiotics and 1 mg/kg of methylprednisolone were started. She had rapid deterioration with increasing oxygen requirements and was ultimately intubated. Thereafter, bronchoscopy showed diffuse alveolar hemorrhage (DAH). The infectious work up was negative, including sputum/bronchial aspirate culture and viral panels. She developed severe kidney failure though urine showed sterile pyuria with proteinuria concerning for acute interstitial nephritis (AIN). She was initiated on 1g methylprednisolone for three days. However, no improvement noted, and she was initiated on additional therapy with infliximab and immunoglobulin (IVIG). Unfortunately, the patient did not improve following therapy and succumbed to her disease. The case highlights a rare presentation of multiorgan system immune related adverse events following checkpoint inhibitor treatment. Checkpoint inhibitor pneumonitis is a rare complication of ICIs. The risk is higher with anti-PD-1 agents such as nivolumab and pembrolizumab than with anti-PD-L1 agents 2. Additionally, patients with non-small cell lung cancer have a higher risk of ICI induced pneumonitis compared to other tumor types 3. DAH and AIN have both been independently associated with ICI therapy, though the presence of diffuse systemic manifestations as demonstrated in this case has not been reported. Early detection and management are essential for improving patient outcomes, especially among patients who develop high grade pneumonitis. ICIs have become first line therapy for several cancers. As their use increases, identifying patients who are most at risk of developing immune related adverse events becomes paramount. This abstract is funded by: None
Caton et al. (Fri,) studied this question.