Zheng Ya-Wen, Pan Jia-Chao, Wang Jin-Feng, Zhang Jian
Department of Oncology, Central Hospital Affiliated to Shandong First Medical University, Jinan 250000, Shandong Province, China.
Department of Gastroenterology, Central Hospital Affiliated to Shandong First Medical University, Jinan 250000, Shandong Province, China.
World J Radiol. 2024 Sep 28;16(9):482-488. doi: 10.4329/wjr.v16.i9.482.
Immune checkpoint inhibitors (ICIs) are therapeutic agents for advanced and metastatic non-small cell lung cancer (NSCLC) with high clinical antitumor efficacy. However, immune-related adverse events occur in 20% of these patients and often requiring treatment with immunosuppressive agents, such as corticosteroids. Consequently, this may increase the risk of patients to opportunistic infections. pneumonia (PJP), a rare but serious opportunistic infection typically observed in patients with human immunodeficiency virus, can also occur in cancer patients undergoing long-term glucocorticoid treatment.
We report a case of a 56-year-old male with squamous NSCLC treated with triplimab combined with paclitaxel, carboplatin, and radical thoracic radiation therapy. Following this regimen, he developed acute kidney injury (AKI) with elevated creatinine levels. After concurrent radical chemoradiotherapy ended, he developed a grade 3 immune-related AKI. High-dose corticosteroids were administered to treat AKI, and renal function gradually recovered. Corticosteroids were reduced to a dose of 10 mg prednisone equivalent daily eight weeks later; however, he developed severe pneumonia with spontaneous pneumothorax. Next-generation sequencing of the bronchoscopic lavage revealed PJP co-infection with herpes simplex virus 1 and cytomegalovirus. The inflammation was more severe in areas exposed to radiation. Piperacillin-tazobactam, acyclovir, sulfamethoxazole, and trimethoprim were used to control the infection. The patient recovered, and immunotherapy was terminated.
PJP is rare but can occur in patients with ICI adverse events and should be differentiated from tumor progression or immune-related adverse events. Thoracic radiation may increase risk, necessitating careful monitoring and prevention.
免疫检查点抑制剂（ICIs）是用于治疗晚期和转移性非小细胞肺癌（NSCLC）的治疗药物，具有较高的临床抗肿瘤疗效。然而，20%的此类患者会发生免疫相关不良事件，且常常需要使用免疫抑制剂进行治疗，如皮质类固醇。因此，这可能会增加患者发生机会性感染的风险。肺孢子菌肺炎（PJP）是一种罕见但严重的机会性感染，通常见于人类免疫缺陷病毒患者，也可能发生在接受长期糖皮质激素治疗的癌症患者中。
我们报告一例56岁男性鳞状NSCLC患者，接受替雷利珠单抗联合紫杉醇、卡铂及根治性胸部放射治疗。按照该治疗方案，他出现了肌酐水平升高的急性肾损伤（AKI）。在同步根治性放化疗结束后，他发生了3级免疫相关AKI。给予大剂量皮质类固醇治疗AKI，肾功能逐渐恢复。8周后，皮质类固醇减至相当于每日10 mg泼尼松的剂量；然而，他出现了伴有自发性气胸的严重肺炎。支气管灌洗的二代测序显示合并1型单纯疱疹病毒和巨细胞病毒的PJP感染。放疗部位的炎症更为严重。使用哌拉西林-他唑巴坦、阿昔洛韦、磺胺甲恶唑和甲氧苄啶控制感染。患者康复，免疫治疗终止。
PJP罕见，但可发生于ICI不良事件患者，应与肿瘤进展或免疫相关不良事件相鉴别。胸部放疗可能会增加风险，需要仔细监测和预防。
