State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
Graduate School, Guangzhou Medical University, Guangzhou, China.
Immunopharmacol Immunotoxicol. 2023 Dec;45(6):780-787. doi: 10.1080/08923973.2023.2228480. Epub 2023 Jul 3.
Neuromuscular associated respiratory failure is a rare toxicity of immunotherapy for malignant tumors. In most cases, it may overlap with the symptoms of the primary disease or myocarditis, myositis and myasthenia gravis, resulting in difficult etiological diagnosis. Early detection and optimal treatment are still topics that need attention. Here, a case of 51-year-old male lung cancer patient with sintilimab-associated myasthenia gravis, myositis, and myocarditis overlap syndrome involving the diaphragm who developed severe type II respiratory failure was reported. After high-dose methylprednisolone, immunoglobulin and pyridostigmine intravenous injection with non-invasive positive pressure ventilation, the patient's symptoms improved significantly and was discharged. One year later, the patient received immunotherapy again due to tumor progression. After 53 days, he developed dyspnea again. Chest X-ray demonstrated marked elevation of the diaphragm, and the electromyogram demonstrated dysfunction of diaphragm. With rapid diagnosis and timely treatment, the patient was finally discharged safely. A comprehensive search of PubMed, EMBASE was performed to identify all previously reported cases of immune checkpoint inhibitors-associated respiratory failure. The potential mechanisms of respiratory failure caused by ICI-associated diaphragmatic dysfunction may be related to T cell-mediated immune disturbances and we proposed possible diagnostic processes. For patients with unexplained respiratory failure who are receiving immunotherapy, standardized diagnostic strategies should be implemented immediately on admission before deciding whether to conduct a more invasive diagnostic procedure or empirical treatment.
神经肌肉相关呼吸衰竭是恶性肿瘤免疫治疗的一种罕见毒性。在大多数情况下，它可能与原发病或心肌炎、肌炎和重症肌无力的症状重叠，导致难以明确病因诊断。早期发现和最佳治疗仍然是需要关注的问题。本文报道了 1 例 51 岁男性肺癌患者，在接受信迪利单抗治疗后出现重症肌无力、肌炎和心肌炎重叠综合征，累及膈肌，导致严重 II 型呼吸衰竭。经过大剂量甲基泼尼松龙、免疫球蛋白和吡啶斯的明静脉注射联合无创正压通气治疗，患者症状明显改善并出院。1 年后，因肿瘤进展，患者再次接受免疫治疗。53 天后，患者再次出现呼吸困难。胸部 X 线片显示膈肌明显抬高，肌电图显示膈肌功能障碍。经过快速诊断和及时治疗，患者最终安全出院。通过对 PubMed、EMBASE 进行全面检索，确定了所有先前报道的与免疫检查点抑制剂相关的呼吸衰竭病例。ICI 相关膈肌功能障碍导致呼吸衰竭的潜在机制可能与 T 细胞介导的免疫紊乱有关，我们提出了可能的诊断流程。对于正在接受免疫治疗且不明原因呼吸衰竭的患者，应在入院时立即实施标准化诊断策略，然后再决定是否进行更具侵入性的诊断程序或经验性治疗。
