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Yu K, Wang T, An D, Li X, Tang Z. Investigating the disparities among drug categories in drug-induced dermatomyositis: A systematic review. Semin Arthritis Rheum 2024; 67:152478. [PMID: 38833729 DOI: 10.1016/j.semarthrit.2024.152478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 05/03/2024] [Accepted: 05/16/2024] [Indexed: 06/06/2024]
Abstract
Drug-induced dermatomyositis (DIDM) is a rare and underestimated variant of dermatomyositis (DM) characterized by muscle damage and skin rash and related to certain drug exposure. The spectrum of drugs causing DIDM has evolved over time, originally implicating hydroxyurea, penicillamine, and statins as causative agents. Tumor necrosis factor α inhibitors and immune checkpoint inhibitors have also been associated with such conditions. To bridge the gap between current literature and clinical practice, and therefore guide clinicians, we conducted a comprehensive review of English literature from Pubmed, EMBASE, and MEDLINE. Our analysis included demographic data, clinical features, laboratory findings, therapeutic outcomes, and extant research pertaining to the probable pathogenesis of DIDM induced by various drugs. Furthermore, we categorized the drugs involved in DIDM cases into biologics and traditional agents for subsequent statistical analysis. Over time, there has been a gradual accumulation of reported DIDM cases. A total of 69 published DIDM cases were documented in our study, among which 33 should be attributed to biologics and the remaining 36 to traditional drugs. Interestingly, 41 of all DIDM cases had a previous history of malignancies. Additionally, DIDM cases exhibited similar cutaneous and muscular manifestations to classic DM, with the exception of cases induced by hydroxyurea, which did not entail muscle damage. Positive antinuclear antibodies and anti-TIF1-γ autoantibodies have been predominantly observed in biologics-induced cases, while positive anti-TIF1-γ antibodies were merely reported in the cases that were primarily diagnosed with malignant diseases and exposed to ICIs afterwards. Anti-TIF1-γ antibodies may potentially serve as a red flag in the identification of co-existing malignant diseases in DM patients. We also provided a comprehensive summary and exploration of potential mechanisms lying behind drug-induced dermatomyositis. In conclusion, our review consolidates the current literature on DIDM, highlighting the evolving spectrum of medications and elucidating the differences in clinical manifestations, laboratory findings, and underlying mechanisms.
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Affiliation(s)
- Kunze Yu
- Zhejiang University School of Medicine Second Affiliated Hospital, Department of Dermatology, Hangzhou, Zhejiang, PR China
| | - Tianxiang Wang
- Zhejiang University School of Medicine Second Affiliated Hospital, Department of Dermatology, Hangzhou, Zhejiang, PR China
| | - Dadao An
- Zhejiang University School of Medicine, Department of Basic Medicine, Hangzhou, Zhejiang, PR China
| | - Xiawei Li
- Zhejiang University School of Medicine Second Affiliated Hospital, Department of Gastrointestinal Surgery, Hangzhou, Zhejiang, PR China
| | - Zhuangli Tang
- Zhejiang University School of Medicine Second Affiliated Hospital, Department of Dermatology, Hangzhou, Zhejiang, PR China.
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Caravan S, Lopez CM, Yeh JE. Causes and Clinical Presentation of Drug-Induced Dermatomyositis: A Systematic Review. JAMA Dermatol 2024; 160:210-217. [PMID: 38198130 DOI: 10.1001/jamadermatol.2023.5418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Importance While several medications are known to induce dermatomyositis (DM), most existing studies are case reports or small case series from a single institution. There is also limited information on DM induced by immune checkpoint inhibitors, which are increasingly used in oncologic therapy. Objective To characterize causes and clinical presentation of drug-induced DM based on the current literature. Evidence Review A systematic review was performed in PubMed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines, from inception to August 22, 2022. Articles meeting preestablished inclusion criteria (written in English and classified as original articles, case reports, literature reviews, and observation letters) were selected and data abstracted. Articles that met the scope of the review were also added from reference lists. When possible, study results were quantitatively combined. Findings In 134 studies (114 from the literature search and 20 additional studies pulled from reference lists) describing 165 cases, 88 patients (53.3%) were female, and the median (IQR) age was 61 (49-69) years. Among the cases of drug-induced DM, the most common associated medications were hydroxyurea (50 [30.3%]), immune checkpoint inhibitors (27 [16.4%]), statins (22 [13.3%]), penicillamine (10 [6.1%]), and tumor necrosis factor inhibitors (10 [6.1%]). Histopathologic testing, when undertaken, helped establish the diagnosis. There was a median (IQR) of 60 (21-288) days between drug initiation and drug-induced DM onset. History of cancer was reported in 85 cases (51.6%). Conclusions and Relevance In this systematic review, drug-induced DM was associated with multiple types of medications, including chemotherapies and immunotherapies. It is essential that dermatologists promptly recognize and diagnose drug-induced DM so that they can guide management to minimize interruption of therapy when possible.
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Affiliation(s)
- Sahar Caravan
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
| | - Christopher M Lopez
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
| | - Jennifer E Yeh
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
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Floyd-Ellis V, Taylor A. Dermatomyositis: a debilitating paraneoplastic phenomenon following a diagnosis of localised squamous cell carcinoma of the cervix. BMJ Case Rep 2023; 16:e253640. [PMID: 37591620 PMCID: PMC10441080 DOI: 10.1136/bcr-2022-253640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2023] [Indexed: 08/19/2023] Open
Abstract
This case report describes the management of a patient, recently diagnosed with Stage IIIC cervical cancer, presenting with significant proximal muscle weakness, dysphagia and cutaneous changes over the hands, knees and outer thighs bilaterally. Following multiple investigations, this clinical presentation was proven to be dermatomyositis as a paraneoplastic phenomenon, a rare diagnosis with cervical cancer.Improvement of the presenting symptoms followed commencement of radical chemoradiation to the primary tumour plus administration of high dose steroids and intravenous immunoglobulins.As demonstrated in this case, and accompanying literature review, dermatomyositis is a rare complication of cervical cancer but should be considered as urgent treatment of the underlying malignancy is imperative. Involving members of the multidisciplinary team, including dieticians and physiotherapists, is of utmost importance to optimise the patient's recovery from such a debilitating diagnosis.
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Affiliation(s)
- Victoria Floyd-Ellis
- School of Medicine, Cardiff University, Cardiff, UK
- Clinical Oncology, Royal Marsden Hospital NHS Trust, London, UK
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Guerra NL, Matas-García A, Serra-García L, Morgado-Carrasco D, Padrosa J, Aldecoa I, Duque Y, Casal-Dominguez M, Muñoz-Braceras S, Aranega R, Moreno-Lozano P, Cantó-Santos J, Garrabou G, Ruiz-Ortiz E, Trallero-Araguas E, Selva-O'Callaghan A, Grau JM, Puig S, Torres-Ruiz J, Mammen AL, Fernandez IP, Milisenda JC. Dermatomyositis unleashed by immune checkpoint inhibitors. Three additional cases and a review of the literature. Autoimmun Rev 2023; 22:103375. [PMID: 37321468 PMCID: PMC10529928 DOI: 10.1016/j.autrev.2023.103375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/04/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVES Immune checkpoint inhibitors (ICI) have revolutionized the treatment of several locally advanced and metastatic tumors. They enhance the effector function of the immune system, consequently leading to different immune-related adverse events. The aim of the present study was to describe three cases of dermatomyositis (DM) triggered by ICI diagnosed at our institution and to perform a review of the literature. METHODS We performed a retrospective clinical, laboratory, and pathological evaluation of three cases of DM triggered by ICI belonging to a cohort of 187 DM patients from the Clinic Hospital Muscle Research Group of Barcelona from January 2009 to July 2022. Moreover, we undertook a narrative review of the literature from January 1990 to June 2022. RESULTS Cases from our institution were triggered by avelumab, an anti-PD-1 ligand (PD-L1), nivolumab, and pembrolizumab, both anti-programmed death-1 (PD-1). One of these patients had locally advanced melanoma, and two had urothelial carcinoma. The severity and response to treatment were heterogeneous among the different cases. All were positive at high titers for anti-TIF1γ autoantibodies; in one of them, serum before the onset of ICI was available, and anti-TIF1γ autoantibodies were already present. RNA expression of IFNB1, IFNG and genes stimulated by these cytokines were markedly elevated in these patients. CONCLUSIONS In conclusion, data from our patients and the narrative review suggest that early positivity to anti-TIF1γ unleashed by ICI may play a role in the development of full-blown DM, at least in some cases.
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Affiliation(s)
- Néstor López Guerra
- Muscle Research Unit, Internal Medicine Service, Hospital Clínic de Barcelona, Universidad de Barcelona IDIBAPS, CIBERER, Barcelona, Spain
| | - Ana Matas-García
- Muscle Research Unit, Internal Medicine Service, Hospital Clínic de Barcelona, Universidad de Barcelona IDIBAPS, CIBERER, Barcelona, Spain
| | - Laura Serra-García
- Dermatology Department, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Daniel Morgado-Carrasco
- Dermatology Department, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Joan Padrosa
- Muscle Research Unit, Internal Medicine Service, Hospital Clínic de Barcelona, Universidad de Barcelona IDIBAPS, CIBERER, Barcelona, Spain; Department of Medical Oncology, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Iban Aldecoa
- Department of Pathology, Biomedical Diagnostic Centre (CDB), Hospital Clinic, University of Barcelona, Spain
| | - Yaiza Duque
- Department of Pathology, Biomedical Diagnostic Centre (CDB), Hospital Clinic, University of Barcelona, Spain
| | - Maria Casal-Dominguez
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, USA
| | - Sandra Muñoz-Braceras
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, USA
| | - Raquel Aranega
- Muscle Research Unit, Internal Medicine Service, Hospital Clínic de Barcelona, Universidad de Barcelona IDIBAPS, CIBERER, Barcelona, Spain
| | - Pedro Moreno-Lozano
- Muscle Research Unit, Internal Medicine Service, Hospital Clínic de Barcelona, Universidad de Barcelona IDIBAPS, CIBERER, Barcelona, Spain
| | - Judith Cantó-Santos
- Muscle Research Unit, Internal Medicine Service, Hospital Clínic de Barcelona, Universidad de Barcelona IDIBAPS, CIBERER, Barcelona, Spain
| | - Glòria Garrabou
- Muscle Research Unit, Internal Medicine Service, Hospital Clínic de Barcelona, Universidad de Barcelona IDIBAPS, CIBERER, Barcelona, Spain
| | - Estíbaliz Ruiz-Ortiz
- Department of Immunology, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona and Institut de Recerca Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ernesto Trallero-Araguas
- Department of Rheumatology, Hospital Universitari Vall d'Hebrón (HVH), Universitat Autònoma der Barcelona (UAB), Barcelona, Spain
| | - Albert Selva-O'Callaghan
- Systemic Autoimmune Diseases Unit. Internal Medicine Service, Hospital Universitari Vall d'Hebrón (HVH), Universitat Autònoma der Barcelona (UAB), Barcelona, Spain
| | - Josep M Grau
- Muscle Research Unit, Internal Medicine Service, Hospital Clínic de Barcelona, Universidad de Barcelona IDIBAPS, CIBERER, Barcelona, Spain
| | - Susana Puig
- Dermatology Department, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Jiram Torres-Ruiz
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Andrew L Mammen
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, USA; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Iago Pinal Fernandez
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, USA; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - José C Milisenda
- Muscle Research Unit, Internal Medicine Service, Hospital Clínic de Barcelona, Universidad de Barcelona IDIBAPS, CIBERER, Barcelona, Spain.
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Nikolaou V, Tsimpidakis A, Stratigos A. Cutaneous Adverse Reactions of Immunotherapy in Patients with Advanced Melanoma. Cancers (Basel) 2023; 15:cancers15072084. [PMID: 37046745 PMCID: PMC10093334 DOI: 10.3390/cancers15072084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Immune checkpoint blockers (ICBs) have been widely used during the last decade for the treatment of various tumors, including advanced and metastatic melanoma. While these agents have improved melanoma patients’ survival rates, they have also been associated with various autoimmune toxicities, with the skin being most commonly affected. The severity of cutaneous toxicity can not only negatively affect patients’ quality of life but can also limit the proper treatment of cancer. Thus, the role of the dermatologist is substantial in early detecting and promptly treating these adverse events. Maculopapular rash, psoriasiform, lichenoid dermatoses and bullous pemphigoid are the most frequent cutaneous adverse events that require immediate intervention. Other rare autoimmune toxicities, e.g., sarcoidosis, dermatomyositis or subacute lupus, have also been reported. In this review, we summarize the aspects of ICB-induced cutaneous toxicities in patients with melanoma, emphasizing their management and treatment options in clinical practice.
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Boutros A, Bottini A, Rossi G, Tanda ET, Spagnolo F, Barletta G, Croce E, Fava P, Parisi A, De Rosa F, Palla M, Marconcini R, Ferrari M, Grandis M, Spallarossa P, Sarocchi M, Arboscello E, Del Mastro L, Lambertini M, Pronzato P, Genova C. Neuromuscular and cardiac adverse events associated with immune checkpoint inhibitors: pooled analysis of individual cases from multiple institutions and literature. ESMO Open 2023; 8:100791. [PMID: 36791639 PMCID: PMC9958259 DOI: 10.1016/j.esmoop.2023.100791] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/12/2022] [Accepted: 01/04/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have revolutionized the management of multiple tumors, due to improved efficacy, quality of life, and safety. While most immune-related adverse events (irAEs) are mild and easily managed, in rare cases such events may be life-threatening, especially those affecting the neuromuscular and cardiac system. The management of neuromuscular/cardiac irAEs is not clear due to the lack of consistent data. Therefore, we carried out a pooled analysis of collected cases from selected Italian centers and individual data from published case reports and case series, in order to improve our understanding of these irAEs. PATIENTS AND METHODS We collected retrospective data from patients treated in six Italian centers with ICIs (programmed cell death protein 1 or programmed death-ligand 1 and/or cytotoxic T-lymphocyte antigen 4 inhibitor) for any solid tumor who experienced neuromuscular and/or cardiovascular toxicity. Then, we carried out a search of case reports and series of neuromuscular/cardiac irAEs from ICIs with any solid tumor. RESULTS This analysis includes cases from Italian institutions (n = 18) and the case reports identified in our systematic literature search (n = 120), for a total of 138 patients. Among these patients, 50 (36.2%) had complete resolution of their neuromuscular/cardiac irAEs, in 21 (15.2%) cases there was a clinical improvement with mild sequelae, and 53 (38.4%) patients died as a result of the irAEs. Factors significantly associated with worse outcomes were early irAE onset, within the first two cycles of ICI (Fisher P < 0.0001), clinical manifestation of both myositis and myocarditis when compared with patients who developed only myositis or myocarditis (chi-square P = 0.0045), and the development of arrhythmia (Fisher P = 0.0070). CONCLUSIONS To the best of our knowledge, this is the largest collection of individual cases of immune-related myocarditis/myositis. Early irAE onset, concurrent development of myositis and myocarditis, as well as occurrence of arrhythmias are associated with worse outcomes and should encourage an aggressive immunomodulatory treatment.
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Affiliation(s)
- A Boutros
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genoa, Genova, Italy.
| | - A Bottini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genoa, Genova, Italy
| | - G Rossi
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - E T Tanda
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - F Spagnolo
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), Plastic Surgery Division, University of Genova, Genoa, Italy
| | - G Barletta
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - E Croce
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - P Fava
- Department of Medical Sciences, Dermatologic Clinic, University of Turin, Torino, Italy
| | - A Parisi
- Department of Life, Health & Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - F De Rosa
- IRCCS Istituto Romagnolo per lo Studio dei Tumori 'Dino Amadori', Meldola (FC), Italy
| | - M Palla
- Department of Skin Cancers, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - R Marconcini
- Azienda Ospedaliero Universitaria Pisana, Medical Oncology Unit, Pisa, Italy
| | - M Ferrari
- Azienda Ospedaliero Universitaria Pisana, Medical Oncology Unit, Pisa, Italy
| | - M Grandis
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal and Infantile Sciences (DINOGMI), University of Genova, Genova, Italy; IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - P Spallarossa
- Cardiovascular Disease Unit, Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | - M Sarocchi
- Cardiovascular Disease Unit, Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | - E Arboscello
- Emergency Department, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - L Del Mastro
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genoa, Genova, Italy; Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - M Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genoa, Genova, Italy; Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - P Pronzato
- Medical Oncology 2, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - C Genova
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genoa, Genova, Italy; Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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Selva-O’Callaghan A, Trallero-Araguás E, Ros J, Gil-Vila A, Lostes J, Agustí A, Riera-Arnau J, Alvarado-Cárdenas M, Pinal-Fernandez I. Management of Cancer-Associated Myositis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2022; 8:91-104. [PMID: 36313478 PMCID: PMC9589595 DOI: 10.1007/s40674-022-00197-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2022] [Indexed: 12/01/2022]
Abstract
Purpose of the Review Cancer-associated myositis (CAM) is defined as when cancer appears within 3 years of myositis onset. Dermatomyositis and seronegative immune–mediated necrotizing myopathy are the phenotypes mostly related to cancer. In general, treatment principles in myositis patients with and without CAM are similar. However, some aspects of myositis management are particular to CAM, including (a) the need for a multidisciplinary approach and a close relationship with the oncologist, (b) the presence of immunosuppressive and antineoplastic drug interactions, and (c) the role of the long-term immunosuppressive therapy as a risk factor for cancer relapse or development of a second neoplasm. In this review, we will also discuss immunotherapy in patients treated with checkpoint inhibitors as a treatment for their cancer. Recent Findings Studies on cancer risk in patients treated with long-term immunosuppressive drugs, in autoimmune diseases such as systemic lupus erythematosus or rheumatoid arthritis, and in solid organ transplant recipients have shed some light on this topic. Immunotherapy, which has been a great advance for the treatment of some types of malignancy, may be also of interest in CAM, given the special relationship between both disorders. Summary Management of CAM is a challenge. In this complex scenario, therapeutic decisions must consider both diseases simultaneously. Supplementary Information The online version contains supplementary material available at 10.1007/s40674-022-00197-2.
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Affiliation(s)
- Albert Selva-O’Callaghan
- Systemic Autoimmune Diseases Unit, Internal Medicine Dept, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Javier Ros
- Medical Oncology Department, Vall d’Hebron General Hospital, Barcelona, Spain
| | - Albert Gil-Vila
- Systemic Autoimmune Diseases Unit, Internal Medicine Dept, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Julia Lostes
- Medical Oncology Department, Vall d’Hebron General Hospital, Barcelona, Spain
| | - Antonia Agustí
- Clinical Pharmacology Service, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Judit Riera-Arnau
- Clinical Pharmacology Service, Vall d’Hebron University Hospital, Barcelona, Spain
| | | | - Iago Pinal-Fernandez
- National Institutes of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, MD USA
- Johns Hopkins University School of Medicine, Baltimore, MD USA
- Faculty of Health Sciences and Faculty of Computer Science, Multimedia and Telecommunications, Universitat Oberta de Catalunya, Barcelona, Spain
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Bhardwaj M, Chiu MN, Pilkhwal Sah S. Adverse cutaneous toxicities by PD-1/PD-L1 immune checkpoint inhibitors: Pathogenesis, Treatment, and Surveillance. Cutan Ocul Toxicol 2022; 41:73-90. [PMID: 35107396 DOI: 10.1080/15569527.2022.2034842] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Introduction-The therapeutic use of humanized monoclonal programmed cell death 1 (PD-1) (pembrolizumab, and nivolumab) and programmed cell death ligand-1 (PD-L1) (atezolizumab, avelumab, durvalumab) immune checkpoint inhibitors (ICPi) as potent anticancer therapies is rapidly increasing. The mechanism of signaling of anti-PD-1/PD-L1 involves triggering cytotoxic CD4+/CD8 + T cell activation and subsequent abolition of cancer cells which induces specific immunologic adverse events that are specific to these therapies. These drugs can cause numerous cutaneous reactions and are characterized as the most frequent immune-related adverse events (irAEs). Majority of cutaneous irAEs range from nonspecific eruptions to detectible skin manifestations, which may be self-limiting and present acceptable skin toxicity profiles, while some may produce life-threatening complications.Objective-.This review aims to illuminate the associated cutaneous irAEs related to drugs used in oncology along with the relevant mechanism(s) and management.Areas covered-Literature was searched using various databases including Pub-Med, Google Scholar, and Medline. The search mainly involved research articles, retrospective studies, case reports, and clinicopathological findings. With this review article, an overview of the cutaneous irAEs with anti-PD-1/PD-L1 therapy, as well as suggestions, have been provided, so that their recognition at early stages could help in better management and would prevent treatment discontinuation.Article highlightsCutaneous adverse effects are the most prevalent immune-related adverse events induced by anti-PD-1/PD-L1 immune-checkpoint antibodies.Cutaneous toxicities mainly manifest in the form of maculopapular rash and pruritus.More specific cutaneous complications can also occur, including vitiligo, worsened psoriasis, lichenoid dermatitis, mucosal involvement (e.g., oral lichenoid reaction), dermatomyositis, lupus erythematosus.Cutaneous manifestations can be life-threatening including Stevens-Johnson syndrome/toxic epidermal necrolysis (TEN).Dermatologic toxicities are usually mild, readily manageable, and rarely result in significant morbidity.Adequate management of the cutaneous adverse event and recognition in early stages could lead to the prevention of worsening of the lesions and limit treatment disruption.
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Affiliation(s)
- Maitry Bhardwaj
- Faculty of Pharmaceutical Sciences, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, 160014, India
| | - Mei Nee Chiu
- Faculty of Pharmaceutical Sciences, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, 160014, India
| | - Sangeeta Pilkhwal Sah
- Faculty of Pharmaceutical Sciences, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, 160014, India
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Hamada N, Maeda A, Takase-Minegishi K, Kirino Y, Sugiyama Y, Namkoong H, Horita N, Yoshimi R, Nakajima H. Incidence and Distinct Features of Immune Checkpoint Inhibitor-Related Myositis From Idiopathic Inflammatory Myositis: A Single-Center Experience With Systematic Literature Review and Meta-Analysis. Front Immunol 2021; 12:803410. [PMID: 34938300 PMCID: PMC8686164 DOI: 10.3389/fimmu.2021.803410] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/22/2021] [Indexed: 01/12/2023] Open
Abstract
Immune checkpoint inhibitor (ICI)-related myositis is a rare, potentially fatal condition that warrants further studies. Its incidence, clinical features, and prognosis remain poorly understood. To address these gaps, we conducted a systematic review and meta-analysis to evaluate the risk of myositis associated with ICI for solid tumors by analyzing phase III randomized controlled trials of anti-programmed death-1/ligand-1 (PD-1/PD-L1) and anti-cytotoxic T-lymphocyte antigen-4 (CTLA-4). To complement this analysis with clinical data, we evaluated published ICI case reports along with cases from our institutional registry. This registry comprised 422 patients treated with ICIs alone or in combination from September 2014 to June 2021. The analysis revealed an incidence of ICI-related myositis in 6,838 patients in 18 randomized controlled trials of 0.38% (odds ratio 1.96; 95% confidence interval 1.02–3.75) for patients receiving ICIs compared with controls. Detailed analysis of 88 cases from the literature search and our registry showed that myositis induced by PD-1 inhibitors was more frequent than that induced by anti-CTLA-4 agents, revealing a clinically diverse trend including myasthenia gravis and myocarditis. Importantly, having ptosis at the time of onset was significantly associated with the development of concomitant myocarditis (odds ratio 3.81; 95% CI 1.48–9.83), which is associated with poor prognosis. Regarding treatment, most patients received glucocorticoids, and some received immunosuppressants. Our study revealed the incidence of ICI-mediated myositis and the clinical features of myocarditis, highlighting the need for recognition and early intervention.
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Affiliation(s)
- Naoki Hamada
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ayaka Maeda
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kaoru Takase-Minegishi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yohei Kirino
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yumiko Sugiyama
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ho Namkoong
- Department of Infectious Diseases, Keio University School of Medicine, Tokyo, Japan
| | - Nobuyuki Horita
- Chemothrapy Center, Yokohama City University Hospital, Yokohama, Japan
| | - Ryusuke Yoshimi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hideaki Nakajima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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10
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Pospischil I, Hoetzenecker W. Arzneimittelexantheme unter modernen zielgerichteten Therapien - Immuncheckpoint- und EGFR-Inhibitoren. J Dtsch Dermatol Ges 2021; 19:1621-1645. [PMID: 34811897 DOI: 10.1111/ddg.14641_g] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/19/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Isabella Pospischil
- Universitätsklinik für Dermatologie und Venerologie, Kepler Universitätsklinikum, Johannes Kepler Universität, Linz, Österreich
| | - Wolfram Hoetzenecker
- Universitätsklinik für Dermatologie und Venerologie, Kepler Universitätsklinikum, Johannes Kepler Universität, Linz, Österreich
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11
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Pospischil I, Hoetzenecker W. Drug eruptions with novel targeted therapies - immune checkpoint and EGFR inhibitors. J Dtsch Dermatol Ges 2021; 19:1621-1643. [PMID: 34811916 PMCID: PMC9299005 DOI: 10.1111/ddg.14641] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/19/2021] [Indexed: 12/25/2022]
Abstract
Given the increasing use of novel targeted therapies, dermatologists are constantly confronted with novel cutaneous side effects of these agents. A rapid diagnosis and appropriate management of these side effects are crucial to prevent impairment of the patients' quality of life and interruptions of essential cancer treatments. Immune checkpoint and EGFR inhibitors are frequently used targeted therapies for various malignancies and are associated with a distinct spectrum of cutaneous adverse events. Exanthematous drug eruptions represent a particular diagnostic challenge in these patients. Immune checkpoint inhibitors can elicit a plethora of immune-related exanthemas, most commonly maculopapular, lichenoid, and psoriasiform eruptions. Additionally, autoimmune bullous dermatoses and exanthemas associated with connective tissue diseases may arise. In cases of severe, atypical or therapy-resistant presentations an extensive dermatological investigation including a skin biopsy is recommended. Topical and systemic steroids are the mainstay of treatment. Papulopustular eruptions represent the major cutaneous adverse effect of EGFR inhibitor therapy, occurring in up to 90 % of patients within the first two weeks of therapy, depending on the agent. Besides topical antibiotics and steroids, oral tetracyclines are the first choice in systemic treatment and can also be used as prophylaxis.
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Affiliation(s)
- Isabella Pospischil
- Department of Dermatology, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Wolfram Hoetzenecker
- Department of Dermatology, Kepler University Hospital, Johannes Kepler University, Linz, Austria
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12
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Piña Y, Evernden BR, Khushalani N, Margolin K, Tawbi H, Tran ND, Macaulay R, Forsyth P, Peguero E. Acute motor axonal neuropathy after ipilimumab and nivolumab treatment in melanoma brain metastases: A case report and review of the literature. SAGE Open Med Case Rep 2021; 9:2050313X211042215. [PMID: 34457306 PMCID: PMC8392782 DOI: 10.1177/2050313x211042215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 08/09/2021] [Indexed: 11/16/2022] Open
Abstract
The use of immune checkpoint inhibitors including ipilimumab and nivolumab has expanded for several tumors including melanoma brain metastasis. These have resulted in a growing spectrum of neurologic immune-related adverse events, including ones that are rare and difficult to diagnose and treat. Here, we present a patient with melanoma brain metastasis who was treated with immune checkpoint inhibitors and developed an Acute Motor Axonal Neuropathy. To our knowledge, this is the first case of Acute Motor Axonal Neuropathy as an immune-related adverse event associated with combination treatment of ipilimumab and nivolumab, who was successfully treated. A 28-year-old woman with metastatic BRAF V600E melanoma developed melanoma brain metastasis and was enrolled on Checkmate 204, a Phase 2 clinical trial using ipilimumab (3 mg/kg intravenous) and nivolumab (1 mg/kg intravenous) every 3 weeks for four cycles, followed by monotherapy with nivolumab (240 mg intravenous) every 2 weeks. A few days after Cycle 2 of ipilimumab and nivolumab, she developed a pure motor axonal neuropathy consistent with Acute Motor Axonal Neuropathy. She was treated with several immunosuppressive treatments including high dose methylprednisolone, immune globulin, and infliximab, and her motor neuropathy eventually improved several months after onset of symptoms. Unfortunately, she had progression of her systemic disease and died several months later. This is the first case reported of Acute Motor Axonal Neuropathy associated with ipilimumab and nivolumab, successfully treated with immune-suppressive therapy. As the field of immunotherapy expands with the increasing use of the immune checkpoint inhibitors, it is critical to increase our knowledge and understanding of the neurologic immune-related adverse events associated with immune checkpoint inhibitors. This includes the spectrum of rare neurologic immune-related adverse events, which can be quite difficult to recognize and treat. Early consultations with neurology may expedite a diagnosis and treatment plan in patients with unexplained weakness receiving immune checkpoint inhibitor therapy.
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Affiliation(s)
- Yolanda Piña
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center (MCC) & Research Institute, Tampa, FL, USA
- H. Lee Moffitt Cancer Center (MCC) & Research Institute, Tampa, FL, USA
| | - Brittany R. Evernden
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center (MCC) & Research Institute, Tampa, FL, USA
- H. Lee Moffitt Cancer Center (MCC) & Research Institute, Tampa, FL, USA
| | - Nikhil Khushalani
- H. Lee Moffitt Cancer Center (MCC) & Research Institute, Tampa, FL, USA
| | | | - Hussein Tawbi
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nam D. Tran
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center (MCC) & Research Institute, Tampa, FL, USA
- H. Lee Moffitt Cancer Center (MCC) & Research Institute, Tampa, FL, USA
| | - Robert Macaulay
- H. Lee Moffitt Cancer Center (MCC) & Research Institute, Tampa, FL, USA
| | - Peter Forsyth
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center (MCC) & Research Institute, Tampa, FL, USA
- H. Lee Moffitt Cancer Center (MCC) & Research Institute, Tampa, FL, USA
| | - Edwin Peguero
- Department of Neuro-Oncology, H. Lee Moffitt Cancer Center (MCC) & Research Institute, Tampa, FL, USA
- H. Lee Moffitt Cancer Center (MCC) & Research Institute, Tampa, FL, USA
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13
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Estenaga A, Rodriguez-Garijo N, Tomás-Velázquez A, Antoñanzas-Pérez J, Alvarez-Gigli ML, García-Tobar L, Espaa-Alonso A, Salido-Vallejo R. Immunotherapy-intensified paraneoplastic dermatomyositis. Indian J Dermatol Venereol Leprol 2021; 88:93-96. [PMID: 34491672 DOI: 10.25259/ijdvl_1306_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 06/01/2021] [Indexed: 11/04/2022]
Affiliation(s)
- A Estenaga
- Department of Dermatology, Clínica Universidad de Navarra, Pamplona, Spain
| | - N Rodriguez-Garijo
- Department of Dermatology, Clínica Universidad de Navarra, Pamplona, Spain
| | - A Tomás-Velázquez
- Department of Dermatology, Clínica Universidad de Navarra, Pamplona, Spain
| | - J Antoñanzas-Pérez
- Department of Dermatology, Clínica Universidad de Navarra, Pamplona, Spain
| | - M L Alvarez-Gigli
- Department of Pathology, Clínica Universidad de Navarra, Pamplona, Spain
| | - L García-Tobar
- Department of Pathology, Clínica Universidad de Navarra, Pamplona, Spain
| | - A Espaa-Alonso
- Department of Dermatology, Clínica Universidad de Navarra, Pamplona, Spain
| | - R Salido-Vallejo
- Department of Dermatology, Clínica Universidad de Navarra, Pamplona, Spain
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14
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Sollena P, Cappilli S, Federico F, Schinzari G, Tortora G, Peris K. "Skin rashes" and immunotherapy in melanoma: distinct dermatologic adverse events and implications for therapeutic management. Hum Vaccin Immunother 2021; 18:1889449. [PMID: 33759689 PMCID: PMC9122307 DOI: 10.1080/21645515.2021.1889449] [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] [Indexed: 12/17/2022] Open
Abstract
Immune checkpoint inhibitors have shown efficacy in the treatment of different cancers by stimulating the antitumoral activity of the patient’s immune system, representing a major breakthrough in the field of cancer therapy. Monoclonal antibodies including anti-cytotoxic T-lymphocyte–associated protein 4, anti–programmed cell death protein 1 and its ligand inhibitors have been approved for advanced melanoma among other solid cancers. Although immunotherapy demonstrated a good safety profile, a new spectrum of multisystemic immune-related adverse events has been recently reported due to their use. Cutaneous reactions represent one of the leading adverse events, often reported in literature as “skin rash”, and rarely further characterized in distinct dermatologic entities. Herein we describe the distinctive cutaneous rashes occurring during immunotherapies for advanced melanoma, discussing implications in the treatment management.
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Affiliation(s)
- Pietro Sollena
- Dermatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Simone Cappilli
- Dermatologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Federico
- Department of Pathology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Schinzari
- Department of Medical Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giampaolo Tortora
- Department of Medical Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Ketty Peris
- Dermatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Dermatologia, Università Cattolica del Sacro Cuore, Rome, Italy
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15
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Kalinich M, Murphy W, Wongvibulsin S, Pahalyants V, Yu KH, Lu C, Wang F, Zubiri L, Naranbhai V, Gusev A, Kwatra SG, Reynolds KL, Semenov YR. Prediction of severe immune-related adverse events requiring hospital admission in patients on immune checkpoint inhibitors: study of a population level insurance claims database from the USA. J Immunother Cancer 2021; 9:e001935. [PMID: 33789879 PMCID: PMC8016099 DOI: 10.1136/jitc-2020-001935] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Immune-related adverse events (irAEs) are a serious side effect of immune checkpoint inhibitor (ICI) therapy for patients with advanced cancer. Currently, predisposing risk factors are undefined but understanding which patients are at increased risk for irAEs severe enough to require hospitalization would be beneficial to tailor treatment selection and monitoring. METHODS We performed a retrospective review of patients with cancer treated with ICIs using unidentifiable claims data from an Aetna nationwide US health insurance database from January 3, 2011 to December 31, 2019, including patients with an identified primary cancer and at least one administration of an ICI. Regression analyses were performed. Main outcomes were incidence of and factors associated with irAE requiring hospitalization in ICI therapy. RESULTS There were 68.8 million patients identified in the national database, and 14 378 patients with cancer identified with at least 1 administration of ICI in the study period. Patients were followed over 19 117 patient years and 504 (3.5%) developed an irAE requiring hospitalization. The incidence of irAEs requiring hospitalization per patient ICI treatment year was 2.6%, rising from 0% (0/71) in 2011 to 3.7% (93/2486) in 2016. Combination immunotherapy (OR: 2.44, p<0.001) was associated with increased odds of developing irAEs requiring hospitalization, whereas older patients (OR 0.98 per additional year, p<0.001) and those with non-lung cancer were associated with decreased odds of irAEs requiring hospitalization (melanoma OR: 0.70, p=0.01, renal cell carcinoma OR: 0.71, p=0.03, other cancers OR: 0.50, p<0.001). Sex, region, zip-code-imputed income, and zip-code unemployment were not associated with incidence of irAE requiring hospitalization. Prednisone (72%) and methylprednisolone (25%) were the most common immunosuppressive treatments identified in irAE hospitalizations. CONCLUSIONS We found that 3.5% of patients initiating ICI therapy experienced irAEs requiring hospitalization and immunosuppression. The odds of irAEs requiring hospitalization were higher with younger age, treatment with combination ICI therapy (cytotoxic T lymphocyte-associated 4 and programmed cell death protein 1 (PD-1) or programmed death-ligand 1 (PD-L1)), and lower for other cancers compared with patients on PD-1 or PD-L1 inhibitors with lung cancer. This evidence from the first nationwide study of irAEs requiring hospitalization in the USA identified the real-world epidemiology, risk factors, and treatment patterns of these irAEs which may guide treatment and management decisions.
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Affiliation(s)
| | - William Murphy
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard Business School, Boston, Massachusetts, USA
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shannon Wongvibulsin
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vartan Pahalyants
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard Business School, Boston, Massachusetts, USA
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kun-Hsing Yu
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Chenyue Lu
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Feicheng Wang
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Leyre Zubiri
- Department of Oncology, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Vivek Naranbhai
- Department of Oncology, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
- Department of Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Alexander Gusev
- Department of Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Shawn G Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kerry L Reynolds
- Department of Oncology, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Yevgeniy R Semenov
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
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16
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Bax CE, Maddukuri S, Ravishankar A, Pappas-Taffer L, Werth VP. Environmental triggers of dermatomyositis: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:434. [PMID: 33842655 PMCID: PMC8033368 DOI: 10.21037/atm-20-3719] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Dermatomyositis (DM) is an autoimmune disease that affects the skin, lungs, and muscle. Although the pathogenesis of DM is not completely understood, several environmental triggers have been linked to DM onset or flare. This article specifically examines the effects of herbal supplements, drugs, infections, ultraviolet (UV) radiation, and environmental pollutants on the onset or exacerbation of DM. Herbal supplements such as Spirulina platensis, Aphanizomenon flos-aquae, Chlorella, Echinacea, and Alfalfa have been implicated and are frequently used in health foods. Medications such as hydroxyurea, TNF-α inhibitors, immune checkpoint inhibitors (ICI), and penicillamine, as well as certain viral infections, such as parvovirus B19, coxsackie virus, polyomavirus, Epstein-Barr virus (EBV), hepatitis, influenza, and human immunodeficiency viruses (HIV) have been associated with DM onset. Bacterial infections and vaccinations have also been linked to the development of DM. Additional environmental factors, including UV radiation and air pollutants, such as silica, biological/mineral dust, and particulate air matter from vehicle and industrial emissions, may also play a role in DM pathogenesis. Overall, there is general agreement that an autoimmune attack of the skin, muscle, and lungs in DM can be triggered by various environmental factors and warrants further investigation.
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Affiliation(s)
- Christina E Bax
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Spandana Maddukuri
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Adarsh Ravishankar
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa Pappas-Taffer
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
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17
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Kartolo A, Towheed T, Mates M. A case of successful pembrolizumab rechallenge in a patient with non-small-cell lung cancer and grade 3 dermatomyositis. Immunotherapy 2021; 13:477-481. [PMID: 33626928 DOI: 10.2217/imt-2020-0309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
We report a case of dermatomyositis in a 59-year old female with advanced non-small-cell lung cancer post one cycle of first-line pembrolizumab monotherapy. Her symptoms resolved with high-dose methyl-prednisolone and subsequent prolonged oral prednisone taper over 11 weeks. She achieved durable response over 6 months without further pembrolizumab and was successfully rechallenged without recurrent high-grade immunotoxicity. To our knowledge, this is the only case of severe immune-related dermatomyositis successfully rechallenged with immunotherapy. In this case report, we highlight that dermatomyositis remains a clinical diagnosis with no reliable autoimmune antibody marker. It is a rare immune-related adverse event for which clinicians must remain highly vigilant. We also discuss the rationale and clinical factors to consider on immunotherapy rechallenge decisions.
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Affiliation(s)
- Adi Kartolo
- Department of Medical Oncology, Queen's University, Kingston K7L 2V7, Canada.,Kingston Health Sciences Centre, Kingston Ontario, Kingston K7L 2V7, Canada
| | - Tanveer Towheed
- Kingston Health Sciences Centre, Kingston Ontario, Kingston K7L 2V7, Canada.,Department of Medicine, Queen's University, Kingston K7L 2V7, Canada
| | - Mihaela Mates
- Department of Medical Oncology, Queen's University, Kingston K7L 2V7, Canada.,Kingston Health Sciences Centre, Kingston Ontario, Kingston K7L 2V7, Canada
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18
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Abstract
This update begins with muscle manifestations of coronavirus 2019. They may include myalgias and elevations in serum creatine kinase. It is unknown whether there is direct muscle invasion and how often the critically ill have muscle sequelae. Regarding autoimmune myopathies, a retrospective study of statin-induced necrotizing myopathy is covered. A relatively large proportion of patients had normal strength at presentation. Examples of dermatomyositis associated with immune checkpoint inhibitors are provided including one with cytokine storm. A report of juvenile dermatomyositis with severe abdominal complications is noteworthy. Two articles address unusual associations with inclusion body myositis, namely, spinocerebellar ataxias and granuloma myositis. In the category of muscular dystrophies, a relatively large single center study of the outcome of scapulothoracic arthrodesis for facioscapulohumeral muscular dystrophy is discussed and a article on anoctaminopathies with pauci- or asymptomatic hyperCKemia.
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19
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Management of Immune-Related Cutaneous Adverse Reactions to PD-1 and PD-L1 Inhibitors for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2020. [DOI: 10.1007/s13671-020-00314-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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20
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Toripalimab-Induced Dermatomyositis in a Patient with Metastatic Melanoma. Dermatol Ther (Heidelb) 2020; 10:863-867. [PMID: 32445174 PMCID: PMC7367952 DOI: 10.1007/s13555-020-00396-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Indexed: 01/08/2023] Open
Abstract
Toripalimab is a monoclonal antibody targeting programmed cell death protein 1 (PD-1). It has recently been approved as an immune checkpoint inhibitor in second-line therapies in patients with unresectable or metastatic melanoma; however, it may be associated with various immune-related adverse events (irAEs). Here we report a case of toripalimab-induced dermatomyositis in a patient receiving treatment for metastatic melanoma. The symptoms were relieved by discontinuing toripalimab and administering once-daily intravenous methylprednisolone 1 mg/kg. We suggest that this case serves a warning to clinicians of the need to be aware of the possiblilty of toripalimab-induced dermatomyositis. Early recognition and treatment may prevent progression and improve prognosis of this irAE.
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21
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Simonsen AB, Kaae J, Ellebaek E, Svane IM, Zachariae C. Cutaneous adverse reactions to anti-PD-1 treatment-A systematic review. J Am Acad Dermatol 2020; 83:1415-1424. [PMID: 32320766 DOI: 10.1016/j.jaad.2020.04.058] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 02/06/2023]
Abstract
The use of the humanized monoclonal anti-programmed cell death 1 antibodies pembrolizumab and nivolumab as potent anticancer therapies is rapidly increasing. However, since their approval, numerous cases of cutaneous reactions have been reported. Cutaneous adverse reactions to these agents have yet to be fully characterized and range from nonspecific eruptions to recognizable skin manifestations, which may be localized and vary from mild to life threatening. This systematic review article provides an overview of the various adverse cutaneous reactions to pembrolizumab and nivolumab therapy and offers suggestions for their management.
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Affiliation(s)
- Anne Birgitte Simonsen
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Jeanette Kaae
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Eva Ellebaek
- Department of Oncology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Inge Marie Svane
- Department of Oncology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Claus Zachariae
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
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22
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Abstract
Links between autoimmune rheumatic diseases and cancer continue to be elucidated. In this review, we explore this complex, bidirectional relationship. First, the increased risk of cancer across the breadth of the autoimmune rheumatic diseases is described. The magnitude of risk and types of tumors seen can differ by the type of autoimmune disease, timing of disease course, and even clinical and laboratory features within a particular autoimmune disease, suggesting that targeted cancer screening strategies can be considered. Multiple mechanisms linking autoimmune rheumatic diseases and cancer are discussed, including the development of autoimmunity in the context of naturally occurring anti-tumor immune responses and malignancy arising in the context of inflammation and damage from autoimmunity. Immunosuppression for rheumatic disease can increase risk for certain types of cancers. Finally, immune checkpoint inhibitors, a type of cancer immunotherapy, which cause a variety of inflammatory syndromes of importance to rheumatologists, are reviewed.
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Affiliation(s)
- Laura C Cappelli
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5501 Hopkins Bayview Circle, Arthritis Center, Baltimore, MD, 21224, USA.
| | - Ami A Shah
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Center Tower, Suite 4100, Baltimore, MD, 21224, USA.
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