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This case highlights the management of steroid-refractory immune checkpoint inhibitor pneumonitis, presenting alternative therapies.

May 20, 2026

A41-23 Beyond Steroids: Managing Steroid-Refractory Immune Checkpoint Inhibitor (ICI) Pneumonitis

Key Points

This case highlights the management of steroid-refractory immune checkpoint inhibitor pneumonitis, presenting alternative therapies.
High-flow nasal cannula (HFNC) for oxygen support
Initial treatment with pulse dose IV methylprednisolone and followed by infliximab and IV immunoglobulin therapy
Monitoring oxygen requirements and clinical signs over the treatment period.
Oxygen requirement improved from 50L to 5L after combined therapy with infliximab and IVIG
Patient discharged on a gradual prednisone taper after significant clinical improvement
Patient classified as Grade 3 pneumonitis requiring multi-agent treatment strategy for recovery.

Abstract

Abstract Introduction Immune Checkpoint Inhibitors (ICI) have revolutionized the treatment of various malignancies. However, severe complications such as ICI pneumonitis can occur. This case discusses the management of steroid-refractory ICI pneumonitis, highlighting potential therapeutic strategies. Case A 78 year old female with known history of stage IV squamous cell carcinoma of the lung status post 3 cycles of immunotherapy with ipilimumab and nivolumab, initially presented with dyspnea and cough. She was hypoxic saturating at 40% on room air. CTA chest showed severe emphysema, a small right middle lobe subsegmental pulmonary emboli, and patchy opacities with irregular interstitial thickening throughout the lungs bilaterally. There was concern for pneumonia versus pneumonitis secondary to immunotherapy. The patient required high-flow nasal cannula (HFNC) at 50L with 80% FiO2. Subsequently started on antibiotics, pulse dose steroids with IV Methylprednisolone 125 mg QID (total 7 days of pulse dose prior to taper), and heparin drip for the pulmonary embolism. The patient was found to have steroid-refractory pneumonitis as she had no improvement despite steroids for more than 48 hours. Given the low suspicion for an infectious etiology, antibiotics were discontinued. IV Infliximab was initiated at 5 mg/kg on day 5. However, the patient continued to require HFNC that was difficult to wean. Due to persistently elevated oxygen requirements, the patient was started on an additional immunosuppressive agent, Intravenous Immunoglobulin therapy (IVIG). IVIG was administered for three consecutive days starting on day 14. Her oxygen requirement decreased from 50L to 40L HFNC at 40% FiO2. A second dose of Infliximab on day 21 was given as well. By day 25, her oxygen requirements drastically fell to 5L nasal cannula with significant clinical improvement. She was eventually discharged on a prednisone taper for 4-6 weeks. Discussion Although ICI pneumonitis can develop at any point during or even after therapy, clinical suspicion is highest within the first few months of treatment. Our patient is classified as having Grade 3 pneumonitis, which normally requires IV Methylprednisolone 1-2 mg/kg/d, and is considered steroid refractory if there is no improvement in 48 hours. The addition of a second-line immunosuppressive agent (e.g. Infliximab, IVIG, mycophenolate mofetil, or cyclophosphamide) is recommended. Despite the addition of a second-line immunosuppressive agent (Infliximab), and a higher dose of pulse dose steroids, the patient did not have significant improvement and required additional second-line immunosuppressive agent (IVIG). This case highlights use of multiple agents with steroids as a feasible combination. This abstract is funded by: None

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