Department of Respiratory Medicine, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles , Brussels, Belgium.
Department of Respiratory Medicine, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles , Brussels, Belgium.
Acta Clin Belg. 2020 Aug;75(4):308-310. doi: 10.1080/17843286.2019.1629078. Epub 2019 Jun 9.
Immunotherapy represents a recent milestone in the treatment of lung cancer, particularly with the rapidly expanding development of monoclonal antibodies targeting checkpoint inhibitors in the programmed cell death-1 (PD-1) pathway, such as nivolumab and pembrolizumab. Classical auto-immune side effects of these treatments, often called immune-related adverse events (irAEs), can affect multiple organs, including the lungs in which potentially life-threatening pneumonitis may require rapid treatment with high doses of corticosteroids. Nevertheless, the occurrence of severe infections in cancer patients treated with nivolumab, outside the context of immunosuppressive therapy, is a complication that has rarely been reported in the literature.
We report two cases of severe pulmonary infection with unusual microbes, Mycobacterium tuberculosis and Aspergillus fumigatus, in patients treated with nivolumab for non-small cell lung cancer.
Ruling out pulmonary infections may require extensive investigation, as these may have an atypical presentation due to immunomodulation. Furthermore, treating the patient with corticosteroids for immune-related pneumonia could lead to a fatal outcome in this context. This report highlights the importance of excluding the presence of opportunistic infections and tuberculosis before considering immune-related pulmonary toxicity with or without a history of prior corticosteroid use. These cases also emphasize the potential value of tuberculosis screening in patients treated with PD-1 checkpoint inhibitors.
免疫疗法代表了肺癌治疗的最新里程碑，特别是程序性细胞死亡-1（PD-1）通路中针对检查点抑制剂的单克隆抗体的迅速发展，如纳武利尤单抗和帕博利珠单抗。这些治疗方法的经典自身免疫副作用，通常称为免疫相关不良事件（irAEs），可影响多个器官，包括肺部，其中潜在危及生命的肺炎可能需要用大剂量皮质类固醇迅速治疗。然而，在免疫抑制治疗之外，接受纳武利尤单抗治疗的癌症患者发生严重感染是一种罕见的文献报道的并发症。
我们报告了两例非小细胞肺癌患者接受纳武利尤单抗治疗后发生严重肺部感染的病例，感染的微生物分别为结核分枝杆菌和烟曲霉。
排除肺部感染可能需要广泛的调查，因为免疫调节可能导致其表现不典型。此外，由于免疫相关性肺炎用皮质类固醇治疗可能导致在这种情况下出现致命后果。本报告强调了在考虑有无皮质类固醇使用史的免疫相关性肺毒性之前，排除机会性感染和结核病存在的重要性。这些病例还强调了在接受 PD-1 检查点抑制剂治疗的患者中进行结核病筛查的潜在价值。
