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Bruno F, Palmiero RA, Ferrero B, Franchino F, Pellerino A, Milanesi E, Soffietti R, Rudà R. Pembrolizumab-Induced Isolated Cranial Neuropathy: A Rare Case Report and Review of Literature. Front Neurol 2021; 12:669493. [PMID: 34046006 PMCID: PMC8144636 DOI: 10.3389/fneur.2021.669493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 03/25/2021] [Indexed: 12/14/2022] Open
Abstract
Introduction: Anti-PD1 agents are widely used in the treatment of solid tumors. This has prompted the recognition of a class of immune-related adverse events (irAEs), due to the activation of autoimmune T-cells. Pembrolizumab is an anti-PD1 agent, which has been related to an increased risk of various neurological irAE (n-irAEs). Here, we present a rare case of pembrolizumab-induced neuropathy of cranial nerves. Case Report: A 72-year-old patient was diagnosed with a lung adenocarcinoma in February 2018 (EGFR-, ALK-, and PDL1 90%). According to the molecular profile, pembrolizumab was started. After three administrations, the patient developed facial paresis, ptosis, ophthalmoplegia, and dysphonia. As brain metastases and paraneoplastic markers were excluded, a drug-related disorder was suspected and pembrolizumab was discontinued. A nerve conduction study and electromyography excluded signs of neuropathy and myopathy at four limbs, and repetitive nerve stimulation was negative. However, altered blink reflex and nerve facial conduction were consistent with an acute neuropathy of the cranial district. Thus, the patient was treated with two cycles of intravenous immunoglobulins (IVIg), which rapidly allowed improvement of both symptoms and neurophysiological parameters. However, the patient died in October 2018 for a progression of lung tumor. Discussion: Only 16 cases of pembrolizumab-related neuropathies have been described so far. Our case is of particular interest for the isolated involvement of cranial nerves and the prompt response to IVIg. Conclusion: N-irAEs are insidious conditions that require solid knowledge of onco-immunotherapy complications: it is mandatory not to delay any treatment that would potentially modify the course of a neurological complication.
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Affiliation(s)
- Francesco Bruno
- Department of Neuro Oncology, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Rosa Antonietta Palmiero
- Department of Neuro Oncology, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Bruno Ferrero
- Department of Neurology, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Federica Franchino
- Department of Neuro Oncology, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Alessia Pellerino
- Department of Neuro Oncology, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Enrica Milanesi
- Department of Oncology, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Riccardo Soffietti
- Department of Neuro Oncology, University Hospital of the City of Health and Science of Turin, Turin, Italy
| | - Roberta Rudà
- Department of Neurology, Castelfranco Veneto Hospital, Castelfranco Veneto, Italy
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Abuzinadah AR, Milyani HA, Alshareef A, Bamaga AK, Alshehri A, Kurdi ME. Brucellosis causing subacute motor polyradiculopathy and the pathological correlation of pseudomyopathic electromyography: A case report. Clin Neurophysiol Pract 2020; 5:130-134. [PMID: 32642603 PMCID: PMC7334466 DOI: 10.1016/j.cnp.2020.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/30/2020] [Accepted: 05/18/2020] [Indexed: 11/17/2022] Open
Abstract
Brucellosis may present with subacute polyradiculoneuropathy. Degeneration and regeneration of muscle fiber causes myopathy like features on EMG. Absence of sensory involvement does not exclude subacute polyradiculoneuropathy.
Introduction Brucellosis is a rare cause of polyradiculopathy. We aim to present a case of subacute motor polyradiculopathy (SAMPR), along with the electromyographic pseudomyopathic changes, and their histopathological correlation. Case presentation A 24-year-old man presented with gradually progressive bilateral lower limb weakness for three weeks that progressed to a loss of ambulation in seven weeks. He had no ocular, facial, or sphincteric weakness and no sensory symptoms. He showed normal cognitive, cranial nerve, and upper limb exams. His lower limb power was medical research council (MRC) grade 3 proximally, and 4 distally. His reflexes were grade 2+ in the upper limbs and grade 0 in the lower limbs. The nerve conduction studies were normal. Electromyography (EMG) showed active denervation with a short-duration motor unit potential (MUP) and early recruitment. MRI showed a diffuse enhancement of the lumbosacral nerve roots. Cerebrospinal fluid (CSF) showed a protein of 2.7 g/L and a white blood cells (WBC) count of 420 cells per microliter. Muscle biopsy revealed neurogenic changes with secondary degenerating and regenerating fibers, explaining the small and short MUPs in the EMG. CSF grew Brucella after fourteen days of incubation. Serum showed high antibody titers for the Brucella species “Melitensis” and “Abortus”. The patient started to walk again, ten months after starting a course of antibiotics. Conclusion Neurobrucellosis can present primarily as SAMPR, sparing the sensory system. SAMPR, with ongoing degenerating and regenerating muscle fibers, may explain the pseudomyopathic changes found in electromyographic studies.
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Affiliation(s)
- Ahmad R Abuzinadah
- King Abdulaziz University, College of Medicine, and King Abdulaziz University Hospital, Internal Medicine Department, Neurology Division, Jeddah, Saudi Arabia.,Neuromuscular Unit, King Fahad Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Haneen A Milyani
- King Abdulaziz University, King Abdulaziz University Hospital, Internal Medicine Department, Neurology Division, Jeddah, Saudi Arabia
| | - Aysha Alshareef
- King Abdulaziz University, College of Medicine, and King Abdulaziz University Hospital, Internal Medicine Department, Neurology Division, Jeddah, Saudi Arabia
| | - Ahmed K Bamaga
- King Abdulaziz University, College of Medicine, and King Abdulaziz University Hospital, Pediatric Department, Neurology Division, Jeddah, Saudi Arabia
| | - Abdulraheem Alshehri
- King Abdulaziz University, College of Medicine, and King Abdulaziz University Hospital, Internal Medicine Department, Neurology Division, Jeddah, Saudi Arabia
| | - Maher E Kurdi
- Neuromuscular Unit, King Fahad Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia.,King Abdulaziz University, Pathology Department, College of Medicine, Rabigh, Saudi Arabia
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Dubey D, David WS, Reynolds KL, Chute DF, Clement NF, Cohen JV, Lawrence DP, Mooradian MJ, Sullivan RJ, Guidon AC. Severe Neurological Toxicity of Immune Checkpoint Inhibitors: Growing Spectrum. Ann Neurol 2020; 87:659-669. [PMID: 32086972 DOI: 10.1002/ana.25708] [Citation(s) in RCA: 128] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 12/11/2022]
Abstract
Expanding use of immune-checkpoint inhibitors (ICIs) underscores the importance of accurate diagnosis and timely management of neurological immune-related adverse events (irAE-N). We evaluate the real-world frequency, phenotypes, co-occurring immune-related adverse events (irAEs), and long-term outcomes of severe, grade III to V irAE-N at a tertiary care center over 6 years. We analyze how our experience supports published literature and professional society guidelines. We also discuss these data with regard to common clinical scenarios, such as combination therapy, ICI rechallenge and risk of relapse of irAE-N, and corticosteroid taper, which are not specifically addressed by current guidelines and/or have limited data. Recommendations for management and future irAE-N reporting are outlined. ANN NEUROL 2020;87:659-669.
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Affiliation(s)
- Divyanshu Dubey
- Department of Neurology, Massachusetts General Hospital, Boston, MA.,Department of Neurology, Brigham and Women's Hospital, Boston, MA.,Department of Neurology, and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - William S David
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Kerry L Reynolds
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Donald F Chute
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Nathan F Clement
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Justine V Cohen
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | | | | | - Ryan J Sullivan
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Amanda C Guidon
- Department of Neurology, Massachusetts General Hospital, Boston, MA
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Dubey D, David WS, Amato AA, Reynolds KL, Clement NF, Chute DF, Cohen JV, Lawrence DP, Mooradian MJ, Sullivan RJ, Guidon AC. Varied phenotypes and management of immune checkpoint inhibitor-associated neuropathies. Neurology 2019; 93:e1093-e1103. [PMID: 31405908 DOI: 10.1212/wnl.0000000000008091] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 04/22/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To describe the spectrum, clinical course, and management of neuropathies associated with immune checkpoint inhibitors (ICIs). METHODS Patients with ICI-related neuropathy (irNeuropathy) were identified and their clinical characteristics compared to neuropathy attributed to cytotoxic agents. RESULTS We identified 19 patients with irNeuropathies. ICIs included anti-programmed death-1 (PD1), 9; anti-cytotoxic T-lymphocyte-associated antigen-4 (CTLA4), 2; and combination of anti-CTLA4 and anti-PD1, 8. Median number of ICI doses prior to neuropathy onset was 4. Rate of neuropathies following ICI therapy was 0.7%. Underlying malignancies included melanoma (n = 15), lung adenocarcinoma (n = 3), and cholangiocarcinoma (n = 1). Neuropathy phenotypes were cranial neuropathies with or without meningitis (n = 7), nonlength-dependent polyradiculoneuropathies with and without cranial nerve involvement (n = 6), small-fiber/autonomic neuropathy (n = 2), ANCA-associated mononeuritis multiplex (n = 1), sensory neuronopathy (n = 1), length-dependent sensorimotor axonal polyneuropathy (n = 1), and neuralgic amyotrophy (n = 1). Immune-related adverse events involving other organ systems were common (58%). Corticosteroid use for management of neuropathy was associated with improvement in median modified Rankin Scale score (1 vs 0, p = 0.001) and Inflammatory Neuropathy Cause and Treatment Disability score (2 vs 0.5, p = 0.012) (Class IV). Significantly higher proportion of irNeuropathies had acute or subacute and nonlength-dependent presentations (p < 0.001) and rate of hospitalization for irNeuropathy was also higher (p = 0.002) compared to toxic neuropathy from chemotherapy. CONCLUSION Neuropathy is a rare complication of ICIs that often responds to immunosuppression. Recognition of its wide phenotypic spectrum and distinct clinical characteristics and prompt management with corticosteroids may lead to favorable outcomes.
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Affiliation(s)
- Divyanshu Dubey
- From the Departments of Neurology (D.D., W.S.D., A.C.G.), Medicine (K.L.R., D.F.C., J.V.C., D.P.L., M.J.M., R.J.S.), and Pathology (N.F.C.), Massachusetts General Hospital; Department of Neurology (D.D., A.A.A.), Brigham and Women's Hospital, Boston, MA; and Department of Neurology (D.D.), Mayo Clinic, Rochester, MN
| | - William S David
- From the Departments of Neurology (D.D., W.S.D., A.C.G.), Medicine (K.L.R., D.F.C., J.V.C., D.P.L., M.J.M., R.J.S.), and Pathology (N.F.C.), Massachusetts General Hospital; Department of Neurology (D.D., A.A.A.), Brigham and Women's Hospital, Boston, MA; and Department of Neurology (D.D.), Mayo Clinic, Rochester, MN
| | - Anthony A Amato
- From the Departments of Neurology (D.D., W.S.D., A.C.G.), Medicine (K.L.R., D.F.C., J.V.C., D.P.L., M.J.M., R.J.S.), and Pathology (N.F.C.), Massachusetts General Hospital; Department of Neurology (D.D., A.A.A.), Brigham and Women's Hospital, Boston, MA; and Department of Neurology (D.D.), Mayo Clinic, Rochester, MN
| | - Kerry L Reynolds
- From the Departments of Neurology (D.D., W.S.D., A.C.G.), Medicine (K.L.R., D.F.C., J.V.C., D.P.L., M.J.M., R.J.S.), and Pathology (N.F.C.), Massachusetts General Hospital; Department of Neurology (D.D., A.A.A.), Brigham and Women's Hospital, Boston, MA; and Department of Neurology (D.D.), Mayo Clinic, Rochester, MN
| | - Nathan F Clement
- From the Departments of Neurology (D.D., W.S.D., A.C.G.), Medicine (K.L.R., D.F.C., J.V.C., D.P.L., M.J.M., R.J.S.), and Pathology (N.F.C.), Massachusetts General Hospital; Department of Neurology (D.D., A.A.A.), Brigham and Women's Hospital, Boston, MA; and Department of Neurology (D.D.), Mayo Clinic, Rochester, MN
| | - Donald F Chute
- From the Departments of Neurology (D.D., W.S.D., A.C.G.), Medicine (K.L.R., D.F.C., J.V.C., D.P.L., M.J.M., R.J.S.), and Pathology (N.F.C.), Massachusetts General Hospital; Department of Neurology (D.D., A.A.A.), Brigham and Women's Hospital, Boston, MA; and Department of Neurology (D.D.), Mayo Clinic, Rochester, MN
| | - Justine V Cohen
- From the Departments of Neurology (D.D., W.S.D., A.C.G.), Medicine (K.L.R., D.F.C., J.V.C., D.P.L., M.J.M., R.J.S.), and Pathology (N.F.C.), Massachusetts General Hospital; Department of Neurology (D.D., A.A.A.), Brigham and Women's Hospital, Boston, MA; and Department of Neurology (D.D.), Mayo Clinic, Rochester, MN
| | - Donald P Lawrence
- From the Departments of Neurology (D.D., W.S.D., A.C.G.), Medicine (K.L.R., D.F.C., J.V.C., D.P.L., M.J.M., R.J.S.), and Pathology (N.F.C.), Massachusetts General Hospital; Department of Neurology (D.D., A.A.A.), Brigham and Women's Hospital, Boston, MA; and Department of Neurology (D.D.), Mayo Clinic, Rochester, MN
| | - Meghan J Mooradian
- From the Departments of Neurology (D.D., W.S.D., A.C.G.), Medicine (K.L.R., D.F.C., J.V.C., D.P.L., M.J.M., R.J.S.), and Pathology (N.F.C.), Massachusetts General Hospital; Department of Neurology (D.D., A.A.A.), Brigham and Women's Hospital, Boston, MA; and Department of Neurology (D.D.), Mayo Clinic, Rochester, MN
| | - Ryan J Sullivan
- From the Departments of Neurology (D.D., W.S.D., A.C.G.), Medicine (K.L.R., D.F.C., J.V.C., D.P.L., M.J.M., R.J.S.), and Pathology (N.F.C.), Massachusetts General Hospital; Department of Neurology (D.D., A.A.A.), Brigham and Women's Hospital, Boston, MA; and Department of Neurology (D.D.), Mayo Clinic, Rochester, MN
| | - Amanda C Guidon
- From the Departments of Neurology (D.D., W.S.D., A.C.G.), Medicine (K.L.R., D.F.C., J.V.C., D.P.L., M.J.M., R.J.S.), and Pathology (N.F.C.), Massachusetts General Hospital; Department of Neurology (D.D., A.A.A.), Brigham and Women's Hospital, Boston, MA; and Department of Neurology (D.D.), Mayo Clinic, Rochester, MN.
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