Abstract Introduction Immune-checkpoint inhibitors (ICI) have revolutionized treatment for various cancers. Lung cancer 5-year survival has improved from 14% to 23%. However, these can cause immune-related adverse events (irAEs), and ICI pneumonitis in particular can be life-threatening. We present a case of steroid-refractory ICI-pneumonitis in a patient being treated with durvalumab for squamous cell carcinoma (SCC) of the lung. Case Presentation A 68-year-old woman with COPD, type 2 diabetes, and stage IIIB right lung SCC with endobronchial involvement presented with two weeks of productive cough and dyspnea. She was started on durvalumab after chemoradiation. On admission, she was hypoxic, requiring supplemental oxygen, and a chest x-ray showed new right-sided opacities (Figure 1). Treatment was initiated for presumed community-acquired pneumonia. A follow-up CT Chest demonstrated new right upper lobe consolidation near the right perihilar mass and diffuse ground glass opacities, suggestive of infection or pulmonary edema (Figure 2). Labs were unremarkable. A bronchoscopy was deferred due to increasing oxygen requirements, eventually requiring high-flow nasal cannula therapy. Antibiotics were broadened to vancomycin and cefepime. Autoimmune workup returned negative. ICI pneumonitis was suspected, given recent exposure to durvalumab. Treatment was initiated with high-dose methylprednisolone followed by a prednisone taper for a total of 13 days. Despite steroid therapy, a lack of improvement in respiratory status prompted second-line initiation of IVIG. After two days of non-response, the patient opted to forgo further treatment and transitioned to comfort care. Discussion ICI pneumonitis has an incidence of approximately 3-5%, with a mortality rate of 10 to 17%. ICI pneumonitis is due to immune-mediated inflammation and loss of self-tolerance within lung tissue. Steroid-refractory ICI pneumonitis accounts for 18.5% of referrals for multidisciplinary irAE care. The pneumonitis is graded based on severity and can be asymptomatic to moderately symptomatic (grade 1-2), to severe and life-threatening (grade 3-4). Severe forms require hospitalization and high-dose IV corticosteroids. Refractory cases can be treated with IVIG, infliximab, or mycophenolate, and clinical response can take up to 4 weeks. Our patient only received 2 days of IVIG when she opted to transition to hospice care. ICI pneumonitis can occur at any time during treatment. There is a heightened risk with pre-existing lung diseases (e.g., COPD), prior radiation, and lung carcinoma. Everyone involved in the care of cancer patients needs to be aware of different forms of irAE, including ICI pneumonitis, given the importance of early identification and intervention. This abstract is funded by: None
Parto et al. (Fri,) studied this question.