1
|
Ochenduszko S, Landete L, Martinez DC, Feria AG, Francés C, Torregrosa MD, Maiques IM. Cytokine release syndrome and immune effector cell‑associated neurotoxicity syndrome in a melanoma patient treated with adjuvant pembrolizumab. Exp Ther Med 2024; 28:423. [PMID: 39301256 PMCID: PMC11412105 DOI: 10.3892/etm.2024.12712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 07/11/2024] [Indexed: 09/22/2024] Open
Abstract
The emergence of immune checkpoint inhibitors (ICIs) has significantly improved the prognosis of patients with solid tumors. However, along with their efficacy, new toxicities related to immune system activation have surfaced, some of which pose life-threatening risks. Cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) are among the serious, albeit rare, immune-related adverse effects (irAEs) observed. Although commonly associated with hematologic malignancies and chimeric antigen receptor T cell therapies, CRS has been reported in patients treated with ICIs, with ICANS being a less documented complication. The present study presents a case report of a 76-year-old patient with resected melanoma who developed clinical symptoms of CRS and ICANS following adjuvant pembrolizumab therapy. The patient presented with neurological symptoms of weakness and encephalopathy with confusion, bradypsychia, dysarthria, tremors and visual hallucinations. Laboratory tests revealed elevated serum levels of tumor necrosis factor-alpha and interleukin-6 along with inflammatory markers, hepatic and renal dysfunction, as well as rapidly progressive normochromic-normocytic anemia. Treatment with corticosteroids led to rapid symptom resolution, albeit with subsequent symptom recurrence after tapering its dose. This case underscores the importance of recognizing and managing irAEs associated with ICIs and highlights the need for vigilant monitoring and individualized therapeutic approaches.
Collapse
Affiliation(s)
| | - Lamberto Landete
- Department of Neurology, Doctor Peset University Hospital, 46017 Valencia, Spain
| | | | - Ana García Feria
- Department of Hematology, Doctor Peset University Hospital, 46017 Valencia, Spain
| | - Carla Francés
- Department of Endocrinology, Doctor Peset University Hospital, 46017 Valencia, Spain
| | | | | |
Collapse
|
2
|
Niimoto T, Todaka T, Kimura H, Suzuki S, Yoshino S, Hoashi K, Yamaguchi H. Cytokine release syndrome following COVID-19 infection during treatment with nivolumab for cancer of esophagogastric junction carcinoma: a case report and review. Int J Emerg Med 2024; 17:106. [PMID: 39223460 PMCID: PMC11367929 DOI: 10.1186/s12245-024-00691-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 08/26/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Cytokine release syndrome (CRS) is an acute systemic inflammatory syndrome characterized by fever and multiple organ failure, which is triggered by immunotherapy or certain infections. Immune checkpoint inhibitors rarely cause immune-related adverse event- cytokine release syndrome (irAE-CRS). This article presents a case report of irAE-CRS triggered by coronavirus disease 2019 (COVID-19). CASE PRESENTATION A 60-year-old man with type 2 diabetes received nivolumab treatment for esophagogastric junction carcinoma and experienced two immune-related adverse events: hypothyroidism and skin disorder. Eleven days before his visit to our hospital, he had a fever and was diagnosed with COVID-19. Five days before his visit, he developed a fever again, along with general malaise, water soluble diarrhea, and myalgia of the extremities. On admission, the patient was in a state of multiple organ failure, and although the source of infection was unknown, a tentative diagnosis of septic shock was made. The patient's condition was unstable despite systemic management with antimicrobial agents, high-dose vasopressors, and intravenous fluids. We suspected CRS due to irAE (irAE-CRS) based on his history of nivolumab use. Steroid pulse therapy (methylprednisolone 1 g/day) was started, and the patient temporarily recovered. However, his respiratory condition worsened; consequently, he was placed on a ventilator and tocilizumab was added to the treatment. His muscle strength recovered to the point where he could live at home, and was subsequently discharged. CONCLUSION In patients previously treated with immune checkpoint inhibitors, irAE-CRS should be considered as a differential diagnosis when multiple organ damage is observed in addition to inflammatory findings. It is recommended to start treatment with steroids; if the disease is refractory, other immunosuppressive therapies such as tocilizumab should be introduced as early as possible.
Collapse
Affiliation(s)
- Takahisa Niimoto
- Department of General Internal Medicine, Aso Iizuka Hospital, 3-83, Yoshio-Machi, Iizuka, Fukuoka, 820-8505, Japan.
- Department of Intensive Care Medicine, Aso Iizuka Hospital, 3-83, Yoshio-Machi, Iizuka, Fukuoka, 820-8505, Japan.
| | - Takafumi Todaka
- Department of General Internal Medicine, Aso Iizuka Hospital, 3-83, Yoshio-Machi, Iizuka, Fukuoka, 820-8505, Japan
| | - Hirofumi Kimura
- Department of General Internal Medicine, Aso Iizuka Hospital, 3-83, Yoshio-Machi, Iizuka, Fukuoka, 820-8505, Japan
| | - Shotaro Suzuki
- Department of Intensive Care Medicine, Aso Iizuka Hospital, 3-83, Yoshio-Machi, Iizuka, Fukuoka, 820-8505, Japan
| | - Shumpei Yoshino
- Department of Intensive Care Medicine, Aso Iizuka Hospital, 3-83, Yoshio-Machi, Iizuka, Fukuoka, 820-8505, Japan
| | - Kosuke Hoashi
- Department of Hematology, Aso Iizuka Hospital, 3-83, Yoshio-Machi, Iizuka, Fukuoka, 820-8505, Japan
| | - Hirotaka Yamaguchi
- Department of General Internal Medicine, Aso Iizuka Hospital, 3-83, Yoshio-Machi, Iizuka, Fukuoka, 820-8505, Japan
| |
Collapse
|
3
|
Yu K, Wang T, An D, Li X, Tang Z. Investigating the disparities among drug categories in drug-induced dermatomyositis: A systematic review. Semin Arthritis Rheum 2024; 67:152478. [PMID: 38833729 DOI: 10.1016/j.semarthrit.2024.152478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 05/03/2024] [Accepted: 05/16/2024] [Indexed: 06/06/2024]
Abstract
Drug-induced dermatomyositis (DIDM) is a rare and underestimated variant of dermatomyositis (DM) characterized by muscle damage and skin rash and related to certain drug exposure. The spectrum of drugs causing DIDM has evolved over time, originally implicating hydroxyurea, penicillamine, and statins as causative agents. Tumor necrosis factor α inhibitors and immune checkpoint inhibitors have also been associated with such conditions. To bridge the gap between current literature and clinical practice, and therefore guide clinicians, we conducted a comprehensive review of English literature from Pubmed, EMBASE, and MEDLINE. Our analysis included demographic data, clinical features, laboratory findings, therapeutic outcomes, and extant research pertaining to the probable pathogenesis of DIDM induced by various drugs. Furthermore, we categorized the drugs involved in DIDM cases into biologics and traditional agents for subsequent statistical analysis. Over time, there has been a gradual accumulation of reported DIDM cases. A total of 69 published DIDM cases were documented in our study, among which 33 should be attributed to biologics and the remaining 36 to traditional drugs. Interestingly, 41 of all DIDM cases had a previous history of malignancies. Additionally, DIDM cases exhibited similar cutaneous and muscular manifestations to classic DM, with the exception of cases induced by hydroxyurea, which did not entail muscle damage. Positive antinuclear antibodies and anti-TIF1-γ autoantibodies have been predominantly observed in biologics-induced cases, while positive anti-TIF1-γ antibodies were merely reported in the cases that were primarily diagnosed with malignant diseases and exposed to ICIs afterwards. Anti-TIF1-γ antibodies may potentially serve as a red flag in the identification of co-existing malignant diseases in DM patients. We also provided a comprehensive summary and exploration of potential mechanisms lying behind drug-induced dermatomyositis. In conclusion, our review consolidates the current literature on DIDM, highlighting the evolving spectrum of medications and elucidating the differences in clinical manifestations, laboratory findings, and underlying mechanisms.
Collapse
Affiliation(s)
- Kunze Yu
- Zhejiang University School of Medicine Second Affiliated Hospital, Department of Dermatology, Hangzhou, Zhejiang, PR China
| | - Tianxiang Wang
- Zhejiang University School of Medicine Second Affiliated Hospital, Department of Dermatology, Hangzhou, Zhejiang, PR China
| | - Dadao An
- Zhejiang University School of Medicine, Department of Basic Medicine, Hangzhou, Zhejiang, PR China
| | - Xiawei Li
- Zhejiang University School of Medicine Second Affiliated Hospital, Department of Gastrointestinal Surgery, Hangzhou, Zhejiang, PR China
| | - Zhuangli Tang
- Zhejiang University School of Medicine Second Affiliated Hospital, Department of Dermatology, Hangzhou, Zhejiang, PR China.
| |
Collapse
|
4
|
Patton L, Monteith B, Heffernan P, Herzinger T, Wilson BE. Hemophagocytic lymphohistiocytosis/cytokine release syndrome secondary to neoadjuvant pembrolizumab for triple-negative breast cancer: a case study. Front Oncol 2024; 14:1394543. [PMID: 38919527 PMCID: PMC11196757 DOI: 10.3389/fonc.2024.1394543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 05/10/2024] [Indexed: 06/27/2024] Open
Abstract
As indications for immune checkpoint inhibitors for breast cancer continue to expand, rare toxicities will emerge that require careful consideration and multidisciplinary management. We report the case of a 40-year-old female receiving neoadjuvant pembrolizumab and chemotherapy for locally advanced triple-negative breast cancer who developed cytokine release syndrome (CRS)/hemophagocytic lymphohistiocytosis (HLH). CRS/HLH secondary to pembrolizumab are scarcely documented in the literature and, to our knowledge, have never been reported in the context of neoadjuvant treatment for breast cancer.
Collapse
Affiliation(s)
- Laura Patton
- Department of Oncology, Queen’s University, Kingston, ON, Canada
| | - Bethany Monteith
- Department of Haematology, Queen’s University, Kingston, ON, Canada
| | - Paul Heffernan
- Department of Critical Care Medicine, Queen’s University, Kingston, ON, Canada
| | - Thomas Herzinger
- Division of Dermatology, Department of Medicine, Queen’s University, Kingston, ON, Canada
| | - Brooke E. Wilson
- Department of Oncology, Queen’s University, Kingston, ON, Canada
- Division of Cancer Care and Epidemiology, Queen’s Cancer Research Institute, Kingston, ON, Canada
| |
Collapse
|
5
|
Tanaka T, Taoka M, Makimoto G, Ninomiya K, Higo H, Fujii M, Ichihara E, Ohashi K, Hotta K, Tabata M, Maeda Y. Severe Cytokine Release Syndrome and Immune Effector Cell-associated Neurotoxicity Syndrome in a Man Receiving Immune Checkpoint Inhibitors for Lung Cancer. Intern Med 2024; 63:1261-1267. [PMID: 37722894 PMCID: PMC11116002 DOI: 10.2169/internalmedicine.2429-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/03/2023] [Indexed: 09/20/2023] Open
Abstract
A 55-year-old man with stage IV lung adenocarcinoma was treated with cisplatin, pemetrexed, nivolumab, and ipilimumab. Approximately 100 days after treatment initiation, he became disoriented and presented to the emergency department with a high fever. Blood tests revealed liver and kidney dysfunctions. Subsequently, the patient developed generalized convulsions that required intensive care. He was clinically diagnosed with cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). Organ damage was gradually controlled with immunosuppressive drugs, including steroids, and the patient was discharged. Successful treatment is rare in patients with CRS, including ICANS, during immune checkpoint inhibitor treatment for solid tumors.
Collapse
Affiliation(s)
- Takaaki Tanaka
- Department of Respiratory Medicine, Okayama University Hospital, Japan
| | - Masataka Taoka
- Department of Respiratory Medicine, Okayama University Hospital, Japan
| | - Go Makimoto
- Department of Respiratory Medicine, Okayama University Hospital, Japan
- Center for Clinical Oncology, Okayama University Hospital, Japan
| | - Kiichiro Ninomiya
- Center for Comprehensive Genomic Medicine, Okayama University Hospital, Japan
| | - Hisao Higo
- Department of Respiratory Medicine, Okayama University Hospital, Japan
| | - Masanori Fujii
- Department of Respiratory Medicine, Okayama University Hospital, Japan
| | - Eiki Ichihara
- Department of Respiratory Medicine, Okayama University Hospital, Japan
| | - Kadoaki Ohashi
- Department of Respiratory Medicine, Okayama University Hospital, Japan
| | - Katsuyuki Hotta
- Center for Innovative Clinical Medicine, Okayama University Hospital, Japan
| | - Masahiro Tabata
- Center for Clinical Oncology, Okayama University Hospital, Japan
| | - Yoshinobu Maeda
- Department of Hematology, Oncology, and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| |
Collapse
|
6
|
Ntwali F, Gilliaux Q, Honoré PM. Nivolumab-Induced Cytokine Release Syndrome: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2024; 25:e941835. [PMID: 38625840 PMCID: PMC11034389 DOI: 10.12659/ajcr.941835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 03/03/2024] [Accepted: 01/17/2024] [Indexed: 04/18/2024]
Abstract
BACKGROUND CRS (cytokine release syndrome) is a massive activation of the inflammatory system characterized by a supra-physiological rate of inflammatory cytokines. The interleukin 6 cytokine plays a central role in CRS. The main clinical sign of CRS is fever, but CRS can lead to multiple organ failure in severe cases. CRS is usually described in sepsis, more recently in SARS COV-2 infection, and in chimeric antigen receptor T-cell therapy. However, it can also be associated with immune checkpoint inhibitors (ICIs), which is infrequently described. ICI have growing indications and can lead to CRS by causing an uncontrolled activation of the immune system. There are currently no treatment guidelines for ICI-induced CRS. CASE REPORT We report a rare case of grade 3 CRS induced by nivolumab associated with 5-fluorouracil and oxaliplatin for gastric cancer. The patient was 65-year-old man with an adenocarcinoma of the cardia. CRS developed during the tenth course of treatment and was characterized by fever, hypotension requiring vasopressors, hypoxemia, acute kidney injury, and thrombopenia. The patient was transferred quickly to the Intensive Care Unit. He was treated for suspected sepsis, but it was ruled out after multiple laboratory examinations. There was rapid resolution after infusion of hydrocortisone. CONCLUSIONS The use of ICIs is expanding. Nivolumab-induced CRS is rarely described but can be severe and lead to multiple organ dysfunction; therefore, intensive care practitioners should be informed about this adverse effect. More studies are needed to better understand this condition and establish treatment guidelines.
Collapse
Affiliation(s)
- Francis Ntwali
- Intensive Care Unit, UCL Namur University Hospital, Yvoir, Belgium
| | - Quentin Gilliaux
- Department of Oncology, UCL Namur University Hospital, Yvoir, Belgium
| | | |
Collapse
|
7
|
Caravan S, Lopez CM, Yeh JE. Causes and Clinical Presentation of Drug-Induced Dermatomyositis: A Systematic Review. JAMA Dermatol 2024; 160:210-217. [PMID: 38198130 DOI: 10.1001/jamadermatol.2023.5418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Importance While several medications are known to induce dermatomyositis (DM), most existing studies are case reports or small case series from a single institution. There is also limited information on DM induced by immune checkpoint inhibitors, which are increasingly used in oncologic therapy. Objective To characterize causes and clinical presentation of drug-induced DM based on the current literature. Evidence Review A systematic review was performed in PubMed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines, from inception to August 22, 2022. Articles meeting preestablished inclusion criteria (written in English and classified as original articles, case reports, literature reviews, and observation letters) were selected and data abstracted. Articles that met the scope of the review were also added from reference lists. When possible, study results were quantitatively combined. Findings In 134 studies (114 from the literature search and 20 additional studies pulled from reference lists) describing 165 cases, 88 patients (53.3%) were female, and the median (IQR) age was 61 (49-69) years. Among the cases of drug-induced DM, the most common associated medications were hydroxyurea (50 [30.3%]), immune checkpoint inhibitors (27 [16.4%]), statins (22 [13.3%]), penicillamine (10 [6.1%]), and tumor necrosis factor inhibitors (10 [6.1%]). Histopathologic testing, when undertaken, helped establish the diagnosis. There was a median (IQR) of 60 (21-288) days between drug initiation and drug-induced DM onset. History of cancer was reported in 85 cases (51.6%). Conclusions and Relevance In this systematic review, drug-induced DM was associated with multiple types of medications, including chemotherapies and immunotherapies. It is essential that dermatologists promptly recognize and diagnose drug-induced DM so that they can guide management to minimize interruption of therapy when possible.
Collapse
Affiliation(s)
- Sahar Caravan
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
| | - Christopher M Lopez
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
| | - Jennifer E Yeh
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
| |
Collapse
|
8
|
Yoshimura A, Yamamoto Y, Nishikawa T, Fujita M, Inoue T, Kondo F, Hayashi T, Kawamura N, Nagahara A, Nakai Y, Nakayama M, Nishimura K. Relapsing cytokine release syndrome in a patient with metastatic renal cell carcinoma treated with pembrolizumab and axitinib therapy. Int Cancer Conf J 2024; 13:26-32. [PMID: 38187183 PMCID: PMC10764692 DOI: 10.1007/s13691-023-00630-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/10/2023] [Indexed: 01/09/2024] Open
Abstract
As immune checkpoint inhibitors become more widely available, the optimal management of immune-related adverse events (irAEs) is becoming increasingly important. Although irAEs are diverse, reports on cytokine release syndrome are rare. Here, we report a case of a 48-year-old man with relapsing cytokine release syndrome after receiving pembrolizumab and axitinib combination therapy for metastatic renal cell carcinoma. During dose reduction of prednisolone for immune-related hepatitis on day 33 after starting pembrolizumab plus axitinib, the patient suddenly developed abdominal pain, and a few hours later became hypotensive and poorly oxygenated. Despite the use of a ventilator and high doses of catecholamines, blood pressure and oxygenation could not be maintained. Extracorporeal membrane oxygenation and intra-aortic balloon pumping were also administered. The cytokine release syndrome (CRS) was treated with tocilizumab, and his general condition improved. Lower-grade CRS relapsed four times despite a moderate dose of oral prednisolone with mycophenolate mofetil or tacrolimus. After gradual reduction in prednisolone over 5 months, the patient was discharged from the hospital. Partial remission of renal cell carcinoma continued for 21 months, and salvage radical nephrectomy was performed. The patient remained disease-free without the need for further treatment 9 months after surgery.
Collapse
Affiliation(s)
- Akihiro Yoshimura
- Departments of Urology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuoku, Osaka, 541-8567 Japan
| | - Yoshiyuki Yamamoto
- Departments of Urology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuoku, Osaka, 541-8567 Japan
| | - Tatsuya Nishikawa
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
| | - Masashi Fujita
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
| | - Takako Inoue
- Department of Thoracic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Fuki Kondo
- Departments of Urology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuoku, Osaka, 541-8567 Japan
| | - Takuji Hayashi
- Departments of Urology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuoku, Osaka, 541-8567 Japan
| | - Norihiko Kawamura
- Departments of Urology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuoku, Osaka, 541-8567 Japan
| | - Akira Nagahara
- Departments of Urology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuoku, Osaka, 541-8567 Japan
| | - Yasutomo Nakai
- Departments of Urology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuoku, Osaka, 541-8567 Japan
| | - Masashi Nakayama
- Departments of Urology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuoku, Osaka, 541-8567 Japan
| | - Kazuo Nishimura
- Departments of Urology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuoku, Osaka, 541-8567 Japan
| |
Collapse
|
9
|
Zhou Y, Zheng GH, Li N, Liu JJ, Wang XH, Li YF. Fatal cytokine-release syndrome in a patient receiving toripalimab: a case report. Immunotherapy 2023; 15:641-645. [PMID: 37139989 DOI: 10.2217/imt-2022-0289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
Immune checkpoint inhibitors, a type of immunotherapy, have demonstrated optimal treatment efficacy in inducing durable antitumor responses in various cancers. Cytokine-release syndrome is a rare immune-related adverse event induced by immune checkpoint inhibitors. In our case, a patient with hypopharyngeal squamous cell carcinoma received toripalimab combined with chemotherapy. On the fourth day post treatment, the patient developed fever and hypotension. Laboratory examination indicated myelosuppression, acute kidney injury and disseminated intravascular coagulation. Meanwhile, serum cytokine levels of IL-6, IL-8, IL-10, IL-1β, IFN-γ and the level of hypersensitive C-reactive protein were markedly elevated. The patient was diagnosed with cytokine release syndrome, which progressed rapidly and led to the patient's demise on the fifth day post treatment.
Collapse
Affiliation(s)
- Yang Zhou
- Department of Chemoradiotherapy, Tangshan People's Hospital, No. 65, Shengli Road, Lunan District, Tangshan, 063000, Hebei Province, China
- The Cancer Institute, Tangshan People's Hospital, Tangshan, Hebei, 063000, Hebei Province, China
| | - Guo-Hong Zheng
- Department of Chemoradiotherapy, Tangshan People's Hospital, No. 65, Shengli Road, Lunan District, Tangshan, 063000, Hebei Province, China
| | - Na Li
- Department of Chemoradiotherapy, Tangshan People's Hospital, No. 65, Shengli Road, Lunan District, Tangshan, 063000, Hebei Province, China
| | - Jing-Jing Liu
- Department of Chemoradiotherapy, Tangshan People's Hospital, No. 65, Shengli Road, Lunan District, Tangshan, 063000, Hebei Province, China
| | - Xiao-Hong Wang
- Department of Chemoradiotherapy, Tangshan People's Hospital, No. 65, Shengli Road, Lunan District, Tangshan, 063000, Hebei Province, China
| | - Yu-Feng Li
- The Cancer Institute, Tangshan People's Hospital, Tangshan, Hebei, 063000, Hebei Province, China
| |
Collapse
|
10
|
Shah D, Soper B, Shopland L. Cytokine release syndrome and cancer immunotherapies - historical challenges and promising futures. Front Immunol 2023; 14:1190379. [PMID: 37304291 PMCID: PMC10248525 DOI: 10.3389/fimmu.2023.1190379] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Cancer is the leading cause of death worldwide. Cancer immunotherapy involves reinvigorating the patient's own immune system to fight against cancer. While novel approaches like Chimeric Antigen Receptor (CAR) T cells, bispecific T cell engagers, and immune checkpoint inhibitors have shown promising efficacy, Cytokine Release Syndrome (CRS) is a serious adverse effect and remains a major concern. CRS is a phenomenon of immune hyperactivation that results in excessive cytokine secretion, and if left unchecked, it may lead to multi-organ failure and death. Here we review the pathophysiology of CRS, its occurrence and management in the context of cancer immunotherapy, and the screening approaches that can be used to assess CRS and de-risk drug discovery earlier in the clinical setting with more predictive pre-clinical data. Furthermore, the review also sheds light on the potential immunotherapeutic approaches that can be used to overcome CRS associated with T cell activation.
Collapse
Affiliation(s)
- Deep Shah
- In vivo Services, The Jackson Laboratory, Sacramento, CA, United States
| | - Brian Soper
- Technical Information Services, The Jackson Laboratory, Bar Harbor, ME, United States
| | - Lindsay Shopland
- In vivo Services, The Jackson Laboratory, Sacramento, CA, United States
| |
Collapse
|
11
|
Liu LL, Skribek M, Harmenberg U, Gerling M. Systemic inflammatory syndromes as life-threatening side effects of immune checkpoint inhibitors: case report and systematic review of the literature. J Immunother Cancer 2023; 11:jitc-2022-005841. [PMID: 36878533 PMCID: PMC9990684 DOI: 10.1136/jitc-2022-005841] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 03/08/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are associated with a wide range of immune-related adverse events. As oncological indications for ICIs widen, their rare side effects become increasingly visible in clinical practice and impact therapy decisions.Here, we report a rare case of early-onset, mild cytokine release syndrome (CRS) in a patient who received ICIs for a metastasized renal cell carcinoma, which led to treatment discontinuation.We further provide a systematic review of the literature of CRS and related life-threatening side effects of ICI treatment, such as hemophagocytic lymphohistiocytosis (HLH). We searched Medline, Embase and the Web of Science Core Collection from inception to October 2021 for reports on CRS, cytokine storm, macrophage activation syndrome, HLH, and related hyperinflammatory disorders in patients with solid cancers receiving ICIs. We found n=1866 articles, which were assessed for eligibility independently by two examiners. Of those, n=49 articles reporting on n=189 individuals were eligible for review. We found that the median time from last infusion to the occurrence of CRS/HLH was approximately nine days, while the onset of symptoms varied from immediately after infusion to one month after treatment. Most patients were treated with either corticosteroids or the anti-interleukin 6 (IL-6) antibody tocilizumab, and although the majority of patients recovered, a few cases were fatal. Concomitant IL-6 and ICI treatment were reported as beneficial for both the antitumoral effect and for limiting side effects. Data from international pharmacovigilance databases underscored that ICI-related CRS and HLH are rare events, but we identified significant differences in reported frequencies, which might suggest substantial under-reporting.The results from this first systematic review of CRS/HLH due to ICI therapy highlight that life-threatening systemic inflammatory complications of ICIs are rare and might be associated with fatal outcome in approximately 10% of patients. Limited data support the use of IL-6 inhibitors in combination with ICIs to augment the antitumoral effect and reduce hyperinflammation.
Collapse
Affiliation(s)
- Lisa L Liu
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden .,Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Marcus Skribek
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden.,Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Ulrika Harmenberg
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden.,Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Gerling
- Theme Cancer, Karolinska University Hospital, Stockholm, Sweden .,Department of Biosciences and Nutrition, Karolinska Institute, Stockholm, Sweden
| |
Collapse
|
12
|
Lhuillier M, Brière M, Artifoni M, Chapal M, Peuvrel L, Saint-Jean M. Cemiplimab-induced cytokine-release syndrome: second case reported and review of the literature. Immunotherapy 2023; 15:229-234. [PMID: 36789558 DOI: 10.2217/imt-2021-0306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
Cemiplimab, a human monoclonal antibody directed against PD-1, has provided more options in the treatment of locally advanced or metastatic cutaneous squamous-cell carcinoma at an unresectable state. Immune checkpoint inhibitors can induce several unfavorable reactions generally referred to as immune-related adverse effects. Cytokine-release syndrome is an immune-related adverse event that is infrequent and not well known. Diagnosis is difficult because of the unspecific symptoms (e.g., fever, hypotension) but it can also be life threatening. The authors report the case of a 62-year-old treated by cemiplimab for a cutaneous squamous-cell carcinoma of the diaper fold with iliac and inguinal lymph node extension. He presented with severe cytokine-release syndrome, concluding with the discontinuation of cemiplimab.
Collapse
Affiliation(s)
- Marine Lhuillier
- Department of Medical Oncology, ICO Cancer Center, Saint-Herblain, 44800, France
| | - Magali Brière
- Department of Infectious Disease, ICO Cancer Center, Saint-Herblain, 44800, France
| | - Mathieu Artifoni
- Department of Internal Medicine, University Hospital of Nantes, 44000, France
| | - Marion Chapal
- Departement of Nephrology, Hospital of Vendée, La Roche-Sur-Yon, 85000, France
| | - Lucie Peuvrel
- Department of Medical Oncology, ICO Cancer Center, Saint-Herblain, 44800, France
| | - Mélanie Saint-Jean
- Department of Medical Oncology, ICO Cancer Center, Saint-Herblain, 44800, France
| |
Collapse
|
13
|
Onwuemene OA, Nnoruka CI, Patriquin CJ, Connelly-Smith LS. Therapeutic plasma exchange in the management of immune checkpoint inhibitor-associated immune-related adverse effects: A review. Transfusion 2022; 62:2370-2390. [PMID: 36134464 DOI: 10.1111/trf.17114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/31/2022] [Accepted: 08/31/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Oluwatoyosi A Onwuemene
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Chizoba I Nnoruka
- Division of Hematology/Oncology, Sibley Memorial Hospital, Sibley Memorial Hospital John Hopkins University, Washington, DC, USA
| | - Christopher J Patriquin
- Department of Medicine, Division of Medical Oncology & Hematology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Laura S Connelly-Smith
- Department of Medicine, University of Washington and Fred Hutchinson Cancer Center, Seattle, Washington, USA
| |
Collapse
|
14
|
Murata D, Azuma K, Tokisawa S, Tokito T, Hoshino T. A case of cytokine release syndrome accompanied with COVID-19 infection during treatment with immune checkpoint inhibitors for non-small cell lung cancer. Thorac Cancer 2022; 13:2911-2914. [PMID: 36073307 PMCID: PMC9537879 DOI: 10.1111/1759-7714.14632] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/14/2022] [Accepted: 08/16/2022] [Indexed: 12/01/2022] Open
Abstract
Cytokine release syndrome (CRS) is a systemic inflammatory disease caused by a variety of factors, including infections and certain drugs. A 70‐year‐old man who was diagnosed with a postoperative recurrence of lung adenocarcinoma received nivolumab, ipilimumab, pemetrexed and carboplatin every 3 weeks for two cycles followed by nivolumab and ipilimumab, which resulted in a partial response. Four days after the dose of nivolumab, the patient returned with diarrhea and fever. The patient was diagnosed with COVID‐19 infection accompanied by severe colitis. Although intensive care was performed, the patient suddenly went into cardiopulmonary arrest. Examination revealed an abnormally high interleukin‐6 level, suggesting CRS. This is the first report of a patient with CRS accompanied with COVID‐19 infection during treatment with ICIs. Cytokine release syndrome (CRS) is a systemic inflammatory disease caused by a variety of factors, including infections and certain drugs. Here, we report a case of non‐small cell lung cancer with CRS caused by COVID‐19 infection during treatment with nivolumab and ipilimumab. Fever is a common event in cancer patients, especially in COVID‐19‐infected patients, but when fever develops during cancer immunotherapy, CRS should always be kept in mind.
Collapse
Affiliation(s)
- Daiki Murata
- Division of Respirology, Neurology, and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Koichi Azuma
- Division of Respirology, Neurology, and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Saeko Tokisawa
- Division of Respirology, Neurology, and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Takaaki Tokito
- Division of Respirology, Neurology, and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Tomoaki Hoshino
- Division of Respirology, Neurology, and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| |
Collapse
|
15
|
Katsumoto TR, Wilson KL, Giri VK, Zhu H, Anand S, Ramchandran KJ, Martin BA, Yunce M, Muppidi S. Plasma Exchange for Severe Immune-Related Adverse Events from Checkpoint Inhibitors: An Early Window of Opportunity? IMMUNOTHERAPY ADVANCES 2022; 2:ltac012. [PMID: 35814850 PMCID: PMC9257781 DOI: 10.1093/immadv/ltac012] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/24/2022] [Indexed: 11/29/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of several advanced malignancies leading to durable remission in a subset of patients. Their rapidly expanding use has led to an increased frequency of immune-related adverse events (irAEs). The pathogenesis of irAEs is poorly understood but may involve aberrant activation of T cells leading to inflammatory cytokine release or production of pathogenic antibodies leading to organ damage. Severe irAEs can be extremely debilitating and, in some cases, life threatening. IrAEs may not always be corticosteroid responsive or may require excessively high, often toxic, corticosteroid doses. Therapeutic plasma exchange (PLEX) is a treatment modality that has shown promising results for the management of certain severe irAEs, including irAEs that are not mentioned in current treatment guidelines. PLEX may attenuate ongoing irAEs and prevent delayed irAEs by accelerating clearance of the ICI, or by acutely removing pathogenic antibodies, cytokines, and chemokines. Here, we summarize examples from the literature in which PLEX was successfully used for the treatment of irAEs. We posit that timing may be a critical factor and that earlier utilization of PLEX for life-threatening irAEs may result in more favorable outcomes. In individuals at high risk for irAEs, the availability of PLEX as a potential therapeutic mitigation strategy may encourage life-saving ICI use or rechallenge. Future research will be critical to better define which indications are most amenable to PLEX, particularly to establish the optimal place in the sequence of irAE therapies and to assess the ramifications of ICI removal on cancer outcomes.
Collapse
Affiliation(s)
- Tamiko R Katsumoto
- Department of Medicine, Division of Immunology and Rheumatology, Stanford University School of Medicine , Stanford, CA, USA
| | - Kalin L Wilson
- Department of Medicine, Stanford University School of Medicine, Stanford , CA, USA
| | - Vinay K Giri
- Department of Medicine, Stanford University School of Medicine, Stanford , CA, USA
| | - Han Zhu
- Department of Medicine, Division of Cardiology, Stanford University School of Medicine , Stanford, CA, USA
| | - Shuchi Anand
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine , Stanford, CA, USA
| | - Kavitha J Ramchandran
- Department of Medicine, Division of Oncology, Stanford Cancer Institute , Stanford University School of Medicine, Stanford, CA, USA
| | - Beth A Martin
- Department of Medicine, Division of Hematology, Stanford University School of Medicine , Stanford, CA, USA
| | - Muharrem Yunce
- Department of Pathology, Stanford University School of Medicine, Stanford , CA, USA
| | - Srikanth Muppidi
- Department of Neurology and Neurosciences, Stanford University School of Medicine, Stanford , CA, USA
| |
Collapse
|
16
|
Asano R, Shinoda K, Tsuda R, Hounoki H, Kawataka M, Makino T, Imura J, Hamaguchi Y, Tobe K. Anti-TIF1γ antibody-positive dermatomyositis in a 15-year-old boy with Epstein-Barr virus-related nasopharyngeal cancer receiving nivolumab. Rheumatology (Oxford) 2021; 60:e197-e199. [PMID: 33367923 DOI: 10.1093/rheumatology/keaa832] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ryoko Asano
- First Department of Internal Medicine, Toyama, Japan
| | | | - Reina Tsuda
- First Department of Internal Medicine, Toyama, Japan
| | | | | | | | - Johji Imura
- Department of Diagnostic Pathology, University of Toyama, Toyama, Japan
| | - Yasuhito Hamaguchi
- Department of Dermatology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Kazuyuki Tobe
- First Department of Internal Medicine, Toyama, Japan
| |
Collapse
|
17
|
Urasaki T, Ono M, Mochizuki T, Takeda K, Nishizawa A, Fukagawa E, Fujiwara M, Komai Y, Kitano S, Yuasa T, Yonese J, Takahashi S. Case Report: A Case of Trimethoprim/Sulfamethoxazole-Triggered Hypotensive Shock: Cytokine Release Syndrome Related to Immune Checkpoint Inhibitors and Drug-Induced Hypersensitivity Syndrome. Front Oncol 2021; 11:681997. [PMID: 33996612 PMCID: PMC8121494 DOI: 10.3389/fonc.2021.681997] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/12/2021] [Indexed: 12/19/2022] Open
Abstract
Currently, only a few reports exist on the cytokine release syndrome (CRS) as one of the severe immune-related adverse events (irAEs) induced by immune checkpoint inhibitors (ICIs). Notably, it is very rare that grade 4 CRS related to ICI therapy overlaps with the drug-induced hypersensitivity syndrome (DiHS). A 46-year old woman with metastatic kidney cancer had grade 3 interstitial pneumonitis induced by four cycles of combination therapy of anti-programmed death-1 and anti-cytotoxic T lymphocyte-4 antibodies after right cytoreductive nephrectomy. Prophylactic administration of trimethoprim/sulfamethoxazole (TMP/SMX) was started concomitantly with prednisolone therapy to treat the interstitial pneumonitis. She developed hypotensive shock when reducing the dosage of prednisolone, and required intubation and ventilation using vasopressors at the intensive care unit. She subsequently exhibited prominent leukocytosis and an increased level of C-reactive protein, suggesting markedly increased cytokine levels. Interestingly, facial edema and erythema increased in association with pyrexia, leukocytosis, liver dysfunction, and renal failure, suggesting that she developed DiHS. She received hemodialysis three times, a plasma exchange, and anti-interleukin-6 therapy to treat severe renal dysfunction, a thrombotic thrombocytopenic purpura-suspected condition, and possible grade 4 CRS, respectively. Although these therapies did not elicit sufficient effects, high-dose administration of intravenous immunoglobulin was successful. With steroid mini-pulse therapy and the subsequent administration of prednisolone, she recovered successfully. To the best of our knowledge, this is the first report that ICIs and TMP/SMX can induce hypotensive shock accompanied with CRS and DiHS during immunosuppressive therapy for an irAE. Importantly, the prophylactic administration of TMP/SMX should be performed cautiously to avoid severe drug reactions such as CRS or DiHS.
Collapse
Affiliation(s)
- Tetsuya Urasaki
- Department of Medical Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Makiko Ono
- Department of Medical Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshiaki Mochizuki
- Department of Emergency Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Koichi Takeda
- Department of Infectious Diseases, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Aya Nishizawa
- Department of Dermatology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Eri Fukagawa
- Department of Urology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Motohiro Fujiwara
- Department of Urology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshinobu Komai
- Department of Urology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shigehisa Kitano
- Division of Cancer Immunotherapy Development, Advanced Medical Development Center, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takeshi Yuasa
- Department of Urology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Junji Yonese
- Department of Urology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shunji Takahashi
- Department of Medical Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| |
Collapse
|
18
|
Chhabra N, Kennedy J. A Review of Cancer Immunotherapy Toxicity: Immune Checkpoint Inhibitors. J Med Toxicol 2021; 17:411-424. [PMID: 33826117 DOI: 10.1007/s13181-021-00833-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/08/2021] [Accepted: 02/16/2021] [Indexed: 02/07/2023] Open
Abstract
Cancer immunotherapy, which leverages features of the immune system to target neoplastic cells, has revolutionized the treatment of cancer. The use of these therapies has rapidly expanded in the past two decades. Immune checkpoint inhibitors represent one drug class within immunotherapy with its first agent FDA-approved in 2011. Immune checkpoint inhibitors act by disrupting inhibitory signals from neoplastic cells to immune effector cells, allowing activated T-cells to target these neoplastic cells. Unique adverse effects associated with immune checkpoint inhibitors are termed immune-related adverse effects (irAEs) and are usually immunostimulatory in nature. Almost all organ systems may be affected by irAEs including the dermatologic, gastrointestinal, pulmonary, endocrine, and cardiovascular systems. These effects range from mild to life-threatening, and their onset can be delayed several weeks or months. For mild irAEs, symptomatic care is usually sufficient. For higher grade irAEs, discontinuation of therapy and initiation of immunosuppressive therapy may be necessary. The management of patients with irAEs involves multidisciplinary care coordination with respect to the long-term goals the individual patient. Clinicians must be aware of the unique and sometimes fatal toxicologic profiles associated with immunotherapies to ensure prompt diagnosis and appropriate management.
Collapse
Affiliation(s)
- Neeraj Chhabra
- Cook County Health, Department of Emergency Medicine, Division of Medical Toxicology, 1950 W Polk Street, 7th Floor, Chicago, IL, 60612, USA. .,Toxikon Consortium, Chicago, IL, USA.
| | - Joseph Kennedy
- Cook County Health, Department of Emergency Medicine, Division of Medical Toxicology, 1950 W Polk Street, 7th Floor, Chicago, IL, 60612, USA.,Toxikon Consortium, Chicago, IL, USA
| |
Collapse
|
19
|
Metastasis to Appendix Presenting as Acute Appendicitis-A Rare Case Report and Review of Literature. J Gastrointest Cancer 2021; 52:1114-1118. [PMID: 33484435 DOI: 10.1007/s12029-021-00586-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
|
20
|
Abstract
This update begins with muscle manifestations of coronavirus 2019. They may include myalgias and elevations in serum creatine kinase. It is unknown whether there is direct muscle invasion and how often the critically ill have muscle sequelae. Regarding autoimmune myopathies, a retrospective study of statin-induced necrotizing myopathy is covered. A relatively large proportion of patients had normal strength at presentation. Examples of dermatomyositis associated with immune checkpoint inhibitors are provided including one with cytokine storm. A report of juvenile dermatomyositis with severe abdominal complications is noteworthy. Two articles address unusual associations with inclusion body myositis, namely, spinocerebellar ataxias and granuloma myositis. In the category of muscular dystrophies, a relatively large single center study of the outcome of scapulothoracic arthrodesis for facioscapulohumeral muscular dystrophy is discussed and a article on anoctaminopathies with pauci- or asymptomatic hyperCKemia.
Collapse
|