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Otto F, Seiberl M, Lara B, Moser T, Kleindienst W, Walter WE, Peter K, Wipfler P, Harrer A. Beyond T cell toxicity-Intrathecal chemokine C-X-C motif ligand indicating B cell involvement in immune-related adverse events following checkpoint inhibition: A two-case series and literature review. Eur J Neurol 2024:e16279. [PMID: 38556899 DOI: 10.1111/ene.16279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 02/12/2024] [Accepted: 03/05/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND AND PURPOSE This study was undertaken to raise awareness of a role of B cells in immune checkpoint inhibitor (ICI)-associated neurological immune-related adverse events (nirAE). METHODS A systematic literature review was made, with case observations of a melanoma and a non-small cell lung cancer (NSCLC) patient who developed ICI-associated nirAE with cerebrospinal fluid (CSF) findings indicating B cell involvement. RESULTS Two patients receiving ipilimumab/nivolumab for melanoma and chemotherapy/pembrolizumab for NSCLC developed nirAE in the form of myocarditis/myositis/myasthenia gravis overlap syndrome (triple M) and cerebellitis plus longitudinal transverse myelitis (c-LETM), respectively. Intrathecal inflammation with chemokine C-X-C motif ligand (CXCL13) elevation was present in both patients; the triple M case had acetylcholine receptor antibodies, antititin reactivity, altered CD4/CD8 T cell ratio in blood, and depressed programmed death-1 (PD-1) expression on CSF T cells; the c-LETM case showed intrathecal antibody production and plasma cells. Both patients insufficiently responded to first-line treatment. The NSCLC case improved upon administration of B cell-depleting therapy with rituximab, whereas the melanoma patient died before escalation therapy was initiated. Literature research revealed one additional ICI-associated LETM case with intrathecal CXCL13 elevation, three cases with ICI-associated aquaporin-4 antibody neuromyelitis spectrum disorder, and evidence of B cell-mediated toxicity based on antibody-mediated immune pathologies in ICI-associated immune-related adverse events. CONCLUSIONS The case observations highlight the plethora of uncertainties in diagnosis and treatment of ICI-associated nirAE, exemplify the heterogeneity of immune mechanisms involved, and suggest a role of B cells, which may be underdiagnosed. Intrathecal CXCL13 may serve as a biomarker of B cell involvement in nirAE, supported by intrathecal immunoglobulin synthesis, presence of plasma cells, and/or recruitment of cognate immune cells.
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Affiliation(s)
- Ferdinand Otto
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, Center for Cognitive Neuroscience, member of EpiCARE, Salzburg, Austria
| | - Michael Seiberl
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, Center for Cognitive Neuroscience, member of EpiCARE, Salzburg, Austria
| | - Bieler Lara
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, Center for Cognitive Neuroscience, member of EpiCARE, Salzburg, Austria
| | - Tobias Moser
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, Center for Cognitive Neuroscience, member of EpiCARE, Salzburg, Austria
| | - Waltraud Kleindienst
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, Center for Cognitive Neuroscience, member of EpiCARE, Salzburg, Austria
| | - Wallner-Essl Walter
- Department of Neuroradiology, Christian-Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Koelblinger Peter
- Department of Dermatology and Allergology, Paracelsus Medical University, Salzburg, Austria
| | - Peter Wipfler
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, Center for Cognitive Neuroscience, member of EpiCARE, Salzburg, Austria
| | - Andrea Harrer
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, Center for Cognitive Neuroscience, member of EpiCARE, Salzburg, Austria
- Department of Dermatology and Allergology, Paracelsus Medical University, Salzburg, Austria
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