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Lee CM, Wang M, Rajkumar A, Calabrese C, Calabrese L. A scoping review of vasculitis as an immune-related adverse event from checkpoint inhibitor therapy of cancer: Unraveling the complexities at the intersection of immunology and vascular pathology. Semin Arthritis Rheum 2024; 66:152440. [PMID: 38579593 DOI: 10.1016/j.semarthrit.2024.152440] [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: 12/11/2023] [Revised: 03/05/2024] [Accepted: 03/17/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND/PURPOSE Vasculitis as an immune-related adverse event (irAE) from checkpoint inhibitor therapy (ICI) to treat cancer is a rare clinical event, and little is known regarding its nosology, clinical manifestations, or response to treatment and outcomes. METHODS To address these gaps, we used the Preferred Reporting Items for Systemic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) framework to further define this complication. Two independent PUBMED searches in September and November of 2022 revealed 127 publications with 37 excluded from title by relevance, 43 excluded by article type, and 23 excluded due to lack of biopsy results, or biopsy negative for vasculitis. Twenty-nine documented cases from 24 publications were included for final analysis. Basic demographics, ICI details, timing of onset of vasculitis symptoms, irAE treatment and outcomes were collected. The vasculitides were classified using 2022 ACR/EULAR Vasculitis Classification Criteria as well as 2012 Revised Chapel-Hill Nomenclature. Adaptations from Naidoo et al. 2023 [1] consensus definitions for irAEs were used and efforts were made to classify steroid-responsive versus unresponsive irAEs. RESULTS Of the 29 cases reviewed, the average age of patients was 62.1 ± 11.0, composed of 58.6 % (n = 17) male and 41.3 % (n = 12) female. Prominent cancer types were lung cancer (41.4 %; n = 12), melanoma (41.4 %; n = 12), and renal cancer (10.3 %; n = 3), with majority being stage 4 (75.9 %, n = 22) and stage 3 (10.3 %, n = 3). Only 8 cases met the ACR/EULAR criteria, and by Chapel-Hill Nomenclature, approximately a third were small-vessel vasculitis (31.0 %; n = 9) with n = 4 positive for ANCA. Most biopsies were taken from the skin (37.9 %, n = 11) and kidney (24.1 %, n = 7). Patients were either treated with single (65.5 %, n = 19), dual (17.2 %; n = 5), or sequential (17.2 %; n = 5) ICI regimen which included anti-PD-1 therapy in all but one case, with mean of 8.7 ± 10.5 cycles received. Mean time to onset of symptoms from start of ICI was 7.2 ± 7.8 months, with 55.2 % occurring >3 months since the initial immunotherapy. Vasculitis treatment included glucocorticoids in 96 % of cases and immunotherapy was often discontinued (44.8 %; n = 13). Clinical improvement of irAE was documented in 86.2 % (n = 25). Data were missing in terms of fate of ICI (34.5 %; n = 10) and tumor outcomes (41.4 %; n = 12). Cancer progressed in 20.7 % (n = 6), stable in 34.5 % (n = 10) cases, and 6 patients died of all-causes. CONCLUSION Vasculitis as an irAE appears clinically heterogeneous and rare. Among reported cases with adequate documentation, vasculitis is of delayed onset following the initiation of immunotherapy. Outcomes of ICI-vasculitis were generally favorable, responding to glucocorticoids and immunotherapy withdrawal. There is an urgent need for more standardized reporting of rare irAEs such as vasculitis to clarify clinical risks, classification, relationship to immunotherapy and outcomes.
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Affiliation(s)
- Chan-Mi Lee
- Case Western Reserve University School of Medicine, Cleveland, OH, United States; University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Margaret Wang
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Aarthi Rajkumar
- University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Cassandra Calabrese
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, United States
| | - Leonard Calabrese
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, United States.
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Chen Q, Li D, Zhang G, Zhong J, Lin L, Liu Z. An immune-related adverse event of Behcet's-like syndrome following pembrolizumab treatment. BMC Pulm Med 2024; 24:166. [PMID: 38575924 PMCID: PMC10996300 DOI: 10.1186/s12890-024-02986-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 03/28/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND In recent years, the emergence of immunotherapy has renewed therapeutic modality. Different from traditional anti-tumor therapy, immune-related adverse events of skin, gastrointestinal tract, liver, lung, endocrine glands commonly occurred. At present, only one case of immune-related adverse event of Behcet's-like syndrome following pembrolizumab treatment was reported in USA, and no one is reported in China. CASE PRESENTATION Here, we report a rare case of Behcet's-like symptom following pembrolizumab treatment. A 43-year-old female was diagnosed as lymph node and bone metastasis of adenocarcinoma with unknown primary lesion, probably being of pulmonary origin. She was treated with pembrolizumab 200 mg every three weeks in combination with chemotherapy for 6 cycles, followed by pembrolizumab monotherapy maintenance. However, she developed Behcet's-like syndrome with oral ulcer, genital uler, phlebitis, and vision loss after 9 cycles of pembrolizumab treatment. She was treated with prednisone 5 mg orally three times a day. Two weeks later, dose of glucocorticoid gaven to the patient gradually decreased with improved symptoms. After a treatment-free withdrawal period, the patient requested to continue pembrolizumab treatment. Unfortunately, the above symptoms recurred on the second day following pembrolizumab treatment, and glucocorticoid was taken once again. The symptoms improved and the condition was under control. CONCLUSIONS In view of the exponential growth of immunocheckpoint inhibitors (ICIs) in a variety of tumors, we should be alert to related adverse events, especially the rare rheumatic manifestations.
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Affiliation(s)
- Qiao Chen
- Department of Medical Oncology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian, PR China
| | - Deyu Li
- Department of Medical Oncology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian, PR China
| | - Guifeng Zhang
- Department of Medical Oncology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian, PR China
| | - Jiangming Zhong
- Department of Medical Oncology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian, PR China
| | - Li Lin
- Department of Medical Oncology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian, PR China
| | - Zhenhua Liu
- Department of Medical Oncology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian, PR China.
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Jural LA, Estanho D, Pereira JDSR, Ribeiro-Lages MB, Lima da Silva LS, Cavalcante IL, Maia LC, Andrade BABD, Tenório JR. Lesions in the oral mucosa associated with the use of checkpoint inhibitors: A bibliometric and critical review. SPECIAL CARE IN DENTISTRY 2024; 44:300-313. [PMID: 37287115 DOI: 10.1111/scd.12887] [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: 03/13/2023] [Revised: 05/26/2023] [Accepted: 05/27/2023] [Indexed: 06/09/2023]
Abstract
AIMS Immune-related adverse events (irAEs) linked to the use of immune checkpoint inhibitors (ICIs) have become increasingly frequent. To perform a bibliometric and critical review of the general panorama of publications on oral mucosal lesions (OML) associated with ICIs. METHODS AND RESULTS Systematized searches were performed in four databases. The included studies were organized and bibliometric and clinical data were extracted and analyzed using VantagePoint and Microsoft Excel. Most of the 35 included studies were reports or case series (n = 33/94.2%). The American authors stood out (n = 17/48.5%), with the majority presenting only one publication. Independent groups carried out most of the publications (n = 31/88.5%). Over the years, publications have increased for users of nivolumab and pembrolizumab. In 21 studies (60%), OML were more common in men, between the 6th and 9th decades of life and who had lung carcinoma (n = 13/37.1%). Pembrolizumab (n = 17/48.5%) was the most used ICI. The patients were affected by one or more OML, including: ulcers (n = 28/80%) and erythema (n = 11/31.4%). Systemic corticosteroids (n = 24/68.5%) and the discontinuation of ICI use (n = 18/51.4%) were the main approaches used. CONCLUSION OML related to the use of ICIs have become increasingly common. More accurate data need to be published.
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Affiliation(s)
- Lucas Alves Jural
- Department of Pediatric Dentistry and Orthodontics, Faculdade de Odontologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Daniella Estanho
- Department of Oral Diagnosis and Pathology, Faculdade de Odontologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Juliana da Silva Rangel Pereira
- Department of Oral Diagnosis and Pathology, Faculdade de Odontologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mariana Batista Ribeiro-Lages
- Department of Pediatric Dentistry and Orthodontics, Faculdade de Odontologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Larissa Soares Lima da Silva
- Department of Pediatric Dentistry and Orthodontics, Faculdade de Odontologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Israel Leal Cavalcante
- Department of Oral Diagnosis and Pathology, Faculdade de Odontologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lucianne Cople Maia
- Department of Pediatric Dentistry and Orthodontics, Faculdade de Odontologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Bruno Augusto Benevenuto de Andrade
- Department of Oral Diagnosis and Pathology, Faculdade de Odontologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jefferson R Tenório
- Department of Oral Diagnosis and Pathology, Faculdade de Odontologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
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Bai H, Wang X, Wang Y, Li Y, Guo W, Lv J, Li Y, Hao Z, Pan X. Ornidazole induced Stevens-Johnson syndrome without body surface involved: A case report. Medicine (Baltimore) 2024; 103:e37164. [PMID: 38306526 PMCID: PMC10843558 DOI: 10.1097/md.0000000000037164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/15/2024] [Indexed: 02/04/2024] Open
Abstract
RATIONALE Ornidazole is a synthetic nitroimidazole derivative that is commonly prescribed for antiparasitic or anti-anaerobic infections. It is generally well tolerated, with known side effects including gastrointestinal tract, anaphylaxis, and central nervous system reactions. Ornidazole-induced binocular reactive keratitis and several mucocutaneous lesions have been rarely reported. PATIENT CONCERNS A 52-year-old woman who suffered from vaginitis and received an ornidazole vaginal plug (0.5 g). Approximately 20 minutes after the suppository was inserted into the vagina, her lips were swollen and valva and labia were burning. Her eyes were red, sore, and watery. DIAGNOSIS She was diagnosed as Steven-Johnson syndrome by the ophthalmologist. According to the Naranjo scale, the adverse drug reaction was evaluated to be probable and severe. INTERVENTIONS Dexamethasone was intravenous administrated as anti-inflammatory therapy for 10 days. Eye drops were locally given to relieve edema and promote healing of the epithelium. The symptoms of her eyes, lips, vulva and crissum were soon relieved. OUTCOMES The patient was discharge from hospital with improved symptoms. LESSONS In order to avoid severe adverse effect, the patient should not use metronidazole ether orally or vaginally. The case emphasized the importance of rapid and accurate diagnosis of Steven-Johnson syndrome induced by ornidazole vaginal plug, especially when the eye symptoms were the chief complaint without body skin involved.
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Affiliation(s)
- Hehe Bai
- Department of Pharmacy, Xi’an Central Hospital, Xi’an, PR China
| | - Xiaodong Wang
- Department of Ophthalmology, The First Affiliated Hospital of Northwest University, Xi’an, PR China
| | - Yuanji Wang
- Department of Pharmacy, The First Affiliated Hospital of Northwest University, Xi’an, PR China
| | - Yanhong Li
- Department of Ophthalmology, The First Affiliated Hospital of Northwest University, Xi’an, PR China
| | - Weiyan Guo
- Department of Pharmacy, The First Affiliated Hospital of Northwest University, Xi’an, PR China
| | - Juan Lv
- Department of Pharmacy, The First Affiliated Hospital of Northwest University, Xi’an, PR China
| | - Yamei Li
- Department of Pharmacy, The First Affiliated Hospital of Northwest University, Xi’an, PR China
| | - Zhaoqin Hao
- Department of Ophthalmology, The First Affiliated Hospital of Northwest University, Xi’an, PR China
| | - Xiaoyan Pan
- School of Pharmacy, Health Science Center, Xi’an Jiaotong University, Xi’an, PR China
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Martel J, Hanania HL, Patel AB. Immune checkpoint inhibitor-induced cutaneous toxicities: a review of histopathologic and clinical features. Hum Pathol 2023; 140:144-172. [PMID: 37141978 DOI: 10.1016/j.humpath.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) represent an emerging treatment option for a variety of cancer types. Through inhibition of programmed cell death protein 1 (PD-1), programmed cell death ligand 1 (PD-L1), and/or cytotoxic lymphocyte-associated antigen-4 (CTLA-4), ICIs activate the host's immune system causing a heightened anti-tumor response. However, off-target effects of ICIs can result in numerous different immune-related cutaneous adverse events (irCAEs). Beyond impacting quality of life, irCAEs can lead to dose limitations or discontinuation of anti-cancer therapies. Correct diagnosis is necessary for expedient and appropriate management. Skin biopsies are often performed to increase diagnostic accuracy and guide clinical management. An extensive literature review was performed using the PubMed database to identify the reported clinical and histopathologic features of irCAEs. This comprehensive review primarily details the histopathologic features of various irCAEs reported to date. Clinical presentation and immunopathogenesis are also discussed in relation to histopathology.
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Affiliation(s)
- Julianna Martel
- Department of Dermatology, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA
| | | | - Anisha B Patel
- Department of Dermatology, The University of Texas, MD Anderson Cancer Center, Houston, TX, 77030, USA.
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Martens A, Schauwvlieghe PP, Madoe A, Casteels I, Aspeslagh S. Ocular adverse events associated with immune checkpoint inhibitors, a scoping review. J Ophthalmic Inflamm Infect 2023; 13:5. [PMID: 36811715 PMCID: PMC9947214 DOI: 10.1186/s12348-022-00321-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/11/2022] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICIs) have become an important part of the treatment of multiple cancers, especially for advanced melanoma and non-small cell lung cancer. Some tumors are capable of escaping immunosurveillance by stimulating checkpoints on T-cells. ICIs prevent activation of these checkpoints and thereby stimulate the immune system and indirectly the anti-tumor response. However, the use of ICIs is associated with various adverse events. Ocular side effects are rare but may have a major impact on the quality of life of the patient. METHODS A comprehensive literature search of the medical databases Web of Science, Embase and PubMed was performed. Articles that provided a comprehensive description of a case report containing 1) cancer patient(s) treated with (a combination of) immune checkpoint inhibitors, and 2) assessed occurrence of ocular adverse events, were included. A total of 290 case reports were included. RESULTS Melanoma (n = 179; 61.7%) and lung cancer (n = 56; 19.3%) were the most frequent reported malignancies. The primary used ICIs were nivolumab (n = 123; 42.5%) and ipilimumab (n = 116; 40.0%). Uveitis was most the common adverse event (n = 134; 46.2%) and mainly related to melanoma. Neuro-ophthalmic disorders, including myasthenia gravis and cranial nerve disorders, were the second most common adverse events (n = 71; 24.5%), mainly related to lung cancer. Adverse events affecting the orbit and the cornea were reported in 33 (11.4%) and 30 cases (10.3%) respectively. Adverse events concerning the retina were reported in 26 cases (9.0%). CONCLUSION The aim of this paper is to provide an overview of all reported ocular adverse events related to the use of ICIs. The insights retrieved from this review might contribute to a better understanding of the underlying mechanisms of these ocular adverse events. Particularly, the difference between actual immune-related adverse events and paraneoplastic syndromes might be relevant. These findings might be of great value in establishing guidelines on how to manage ocular adverse events related to ICIs.
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Affiliation(s)
- A. Martens
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - P. P. Schauwvlieghe
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - A. Madoe
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - I. Casteels
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - S. Aspeslagh
- grid.411326.30000 0004 0626 3362Department of Medical Oncology, University Hospital Brussels, Brussels, Belgium
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Neves da Silva HV, Placide J, Duong A, Ronquillo Y, McCabe S, Moshirfar M. Ocular adverse effects of therapeutic biologics. Ther Adv Ophthalmol 2022; 14:25158414211070878. [PMID: 35495617 PMCID: PMC9047051 DOI: 10.1177/25158414211070878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022] Open
Abstract
Biological drugs, termed biologics, are medications that contain or are derived from a living organism (human, animal, or microorganism). With new biological agents being approved by the Food and Drug Administration (FDA) every year, clinicians need to know potential ocular adverse effects that are associated with these drugs. This review provides an overview of ocular adverse effects of biological medications used to treat both ophthalmic and non-ophthalmic diseases. We searched PubMed for relevant case reports, case series, reviews, and clinical trials reporting ocular adverse effects caused by biologics. This review was conducted in June 2021 and investigated the drugs listed in the most updated (April 2021) FDA Purple Book Database of Licensed Biological Products. This review focuses on monoclonal antibodies, interleukins, and receptor fusion proteins. We explore ocular side effects of 33 biological drugs, stating whether they are frequent, common, or rare.
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Affiliation(s)
| | - John Placide
- McGovern Medical School, The University of Texas Health Science Center, Houston, TX, USA
| | - Anne Duong
- McGovern Medical School, The University of Texas Health Science Center, Houston, TX, USA
| | | | | | - Majid Moshirfar
- Hoopes Research Center, 11820 South State Street, Suite 200, Draper, UT 84020, USA
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Abstract
Behcet's syndrome (BS) is a chronic systemic inflammatory vasculitis with a wide range of clinical manifestations including recurrent oral and genital ulcers; cutaneous lesions; and ophthalmic, neurologic, and gastrointestinal involvement. BS has a global distribution but is particularly prevalent in so-called Silk Road populations. Disease onset is usually around the third or fourth decade of life, and the sex ratio is roughly 1:1. Both environmental and genetic factors contribute to the etiology of BS, although the detailed mechanisms remain unclear. At present, there is no laboratory examination with diagnostic value for BS; therefore, a diagnosis is made based on clinical manifestations. The International Study Group diagnostic criteria published in 1990 is the most widely used and recognized, but in order to improve sensitivity, the International Criteria for Behcet's Disease is developed in 2014. Evaluating disease activity in BS is an important basis for treatment selection and monitoring, the simplified Behcet's Disease Current Activity Form (2006 version) is a well-established scoring method. Given that multiple organs are affected in BS, it must be differentiated from other diseases with similar manifestations or that may be induced by drug treatment. The goal of BS treatment is to eradicate triggers and/or aggravating factors, alleviate and control clinical symptoms, prevent and treat any damage to organs, slow disease progression, and improve the patient's quality of life. The clinical management of BS depends on the affected organs and disease severity. In this review, we summarize the current state of knowledge of BS pathogenesis and therapeutic options.
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Affiliation(s)
- Jingjing Chen
- Department of Allergy and Rheumatology, Hospital for Skin Diseases, Institute of Dermatology, Chinese Academy of Medical Sciences, Peking Union Medical College, 12 Jiangwangmiao Street, Nanjing, 210042, China
| | - Xu Yao
- Department of Allergy and Rheumatology, Hospital for Skin Diseases, Institute of Dermatology, Chinese Academy of Medical Sciences, Peking Union Medical College, 12 Jiangwangmiao Street, Nanjing, 210042, China.
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