Jaffer Muhammad, Chung Matthew, Sharda Esha, Ramsakal Asha, Peguero Edwin, Verma Neha, Mokhtari Sepideh
University of South Florida, Tampa, FL, USA.
MD Anderson Cancer Center, Houston, TX, USA.
Clin Med Insights Oncol. 2020 Dec 28;14:1179554920978024. doi: 10.1177/1179554920978024. eCollection 2020.
Immunotherapy agents such as ipilimumab and nivolumab are immensely effective in the treatment of various malignancies. Despite this, neurologic immune-related sequelae (NIRS) have been observed. Prompt diagnosis and treatment is critical to improve patient outcomes. We present a case of a 63-year-old man with stage IV metastatic melanoma beginning treatment with ipilimumab and nivolumab. Gathered history from the patient showed that he had a 3-year presentation of bradykinesia, shuffling gait, and muscle cramping. After one dose, the patient began to have progressively worsening generalized weakness; after receiving the immunotherapy, there was a rapid decline in his health. In addition to weakness, the patient developed diplopia, impaired single breath count, lingual and upper/lower extremity fasciculations, and brisk reflexes. While the lumbar puncture and myasthenia panel were non-diagnostic, the electromyography (EMG) revealed axonal neuropathy and diffuse denervation/reinnervation changes. Furthermore, a magnetic resonance imaging (MRI) displayed fatty replacement of the tongue with a bright tongue sign. These results pointed to the diagnosis of amyotrophic lateral sclerosis (ALS) superimposed onto myasthenic-like syndrome. The patient was started on various treatments; however, unfortunately he died due to acute hypoxic respiratory failure. This case highlights important considerations that must be taken when using immunotherapy, especially in patients with pre-existing neurological deficits. Furthermore, it shows the importance of early diagnosis as treatment can potentially cure adverse sequelae.
免疫治疗药物如伊匹木单抗和纳武单抗在治疗各种恶性肿瘤方面极为有效。尽管如此，仍观察到了神经免疫相关后遗症（NIRS）。及时诊断和治疗对于改善患者预后至关重要。我们报告一例63岁患有IV期转移性黑色素瘤的男性患者，开始接受伊匹木单抗和纳武单抗治疗。从患者处收集的病史显示，他有3年的运动迟缓、拖步和肌肉痉挛症状。一剂治疗后，患者开始出现逐渐加重的全身无力；接受免疫治疗后，他的健康状况迅速恶化。除了无力，患者还出现了复视、单次呼吸计数受损、舌部及上肢/下肢肌束震颤和反射亢进。虽然腰椎穿刺和重症肌无力检查未能确诊，但肌电图（EMG）显示轴索性神经病和弥漫性失神经/再支配改变。此外，磁共振成像（MRI）显示舌部脂肪替代，出现亮舌征。这些结果提示诊断为肌萎缩侧索硬化症（ALS）叠加类重症肌无力综合征。患者开始接受各种治疗；然而，不幸的是，他因急性低氧性呼吸衰竭死亡。该病例突出了使用免疫治疗时必须考虑的重要因素，尤其是在已有神经功能缺损的患者中。此外，它还显示了早期诊断的重要性，因为治疗有可能治愈不良后遗症。
