Bala-Hampton Justin E, Bazzell Angela F, Dains Joyce E
The University of Texas MD Anderson Cancer Center, Houston, Texas.
J Adv Pract Oncol. 2018 May-Jun;9(4):422-428. Epub 2018 May 1.
A 48-year-old gentleman with metastatic melanoma currently receiving the cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) inhibitor, ipilimumab (Yervoy), and the programmed cell death protein 1 (PD-1) inhibitor, nivolumab (Opdivo), returned for evaluation prior to receiving cycle 2. The patient presented with new onset dyspnea and a non-productive cough over the past week, with a temperature of 100.6°F at home on one occasion. He was placed on observation for fever, cough, and shortness of breath. The patient had no previous history of lung disease and was a nonsmoker. Diminished breath sounds were noted on auscultation. However, the patient was without fever or chills, with a heart rate of 101 beats per minute and a blood pressure of 110/75 mm Hg. We obtained a computed tomography (CT) of his chest. The CT demonstrated diffuse ground-glass opacities in his bilateral lower lobes and some minor interstitial thickening of his right middle lobe, possibly suggestive of inflammation or cryptogenic organizing pneumonia. Based on his presentation and CT findings, the patient was initially treated empirically with antibiotics for suspected pneumonia vs. pneumonitis. During the first 12 hours in observation, the patient experienced increasing dyspnea and cough and was admitted to the hospital. Nebulizer treatments were administered with no improvement, so the patient was started on high-dose corticosteroids at 1 mg/kg, and pulmonary and infectious disease consults were ordered. After the administration of steroids, the patient's cough and breathing improved and he remained afebrile, eliciting a high suspicion for immune-related pneumonitis. The patient then underwent bronchoscopy to rule out other etiologies. Bronchoalveolar lavage was performed, which yielded no pathogenic organisms. The patient was placed on a 3-week course of a high-dose steroid taper, following which immunotherapy was reinstated. Within 4 days he again presented with similar symptoms, was restarted on high-dose steroids, and immunotherapy was permanently discontinued.
一名48岁患有转移性黑色素瘤的男性患者，目前正在接受细胞毒性T淋巴细胞相关抗原4（CTLA-4）抑制剂伊匹单抗（Yervoy）和程序性细胞死亡蛋白1（PD-1）抑制剂纳武单抗（Opdivo）治疗，在接受第2周期治疗前前来复诊。患者在过去一周出现新发呼吸困难和干咳，在家时有一次体温达到100.6°F。他因发热、咳嗽和呼吸急促接受观察。该患者既往无肺部疾病史，且不吸烟。听诊时发现呼吸音减弱。然而，患者无发热或寒战，心率为每分钟101次，血压为110/75 mmHg。我们对他的胸部进行了计算机断层扫描（CT）。CT显示双侧下叶弥漫性磨玻璃影以及右中叶一些轻微的间质增厚，可能提示炎症或隐源性机化性肺炎。根据他的临床表现和CT结果，患者最初经验性地接受抗生素治疗，怀疑为肺炎或肺炎性病变。在观察的最初12小时内，患者呼吸困难和咳嗽加重，随后入院。雾化治疗后无改善，因此开始给患者使用1 mg/kg的大剂量糖皮质激素，并安排了肺部和感染病会诊。使用糖皮质激素后，患者的咳嗽和呼吸情况改善，且仍无发热，高度怀疑为免疫相关肺炎。患者随后接受支气管镜检查以排除其他病因。进行了支气管肺泡灌洗，未发现致病微生物。患者接受了为期3周的大剂量糖皮质激素逐渐减量治疗，之后恢复免疫治疗。4天内他再次出现类似症状，再次开始使用大剂量糖皮质激素，免疫治疗被永久停用。
