Vogt-Koyanagi-Harada disease-like posterior uveitis in the course of nivolumab (anti-PD-1 antibody), interposed by vemurafenib (BRAF inhibitor), for metastatic cutaneous malignant melanoma

Abstract

A patient with metastatic cutaneous malignant melanoma developed Vogt-Koyanagi-Harada disease-like posterior uveitis after two nivolumab (anti-PD-1 antibody) injections. Vogt-Koyanagi-Harada disease, with the background of autoimmunity against choroidal melanocytes, suggests nivolumab be working by disintegrating inhibition circuit of T cells against a common epitope shared between melanoma cells and normal melanocytes.

Keywords: BRAF inhibitor; PD‐1; Vogt‐Koyanagi‐Harada disease; nivolumab; uveitis; vemurafenib.

Figure 1

Blackish skin lesion with irregularly surfaced elevation (A) on flexor part of the right forearm of a 60‐year‐old woman in April 2013, which is proven histopathologically as malignant melanoma (x4 low magnification in B with bar = 500 μm, and x40 high magnification in C with bar = 50 μm). Multiple metastatic lesions (D) in the liver with maximum standardized uptake values (SUVmax), ranging from 7.36 to 8.58, together with bony metastases in the sternum (SUVmax = 5.70), cervical (C2) vertebrate (SUVmax = 6.64), and right pubic bone (SUVmax = 3.83), also with a high‐uptake site at the right atrium of the heart (SUVmax = 7.66) in whole‐body 2‐[¹⁸F]fluoro‐2‐deoxy‐D‐glucose (FDG) positron emission tomography fused with computed tomography (PET/CT) on March 10, 2015 (arrows in D). PET/CT on September 29 shows only an atrium lesion (arrow in E) with reduced uptake (SUVmax = 2.94), but no hepatic or bony lesions (E).

Figure 2

Fundus photographs and vertical sections of optical coherence tomographic scans (right eye in left column and left eye in right column) on April 28, 2015 (top four panels) and May 12 (bottom four panels). Note multifocal bumpy appearance in the posterior pole of the fundus (A and B) and wavy retinal pigment epithelium (C and D) in both eyes, with subretinal fluid (arrow in C) in the right eye on April 28. The fundi in both eyes appear normal (E and F) and optical coherence tomography shows normal lining of the retinal pigment epithelium in both eyes (G and H) on May 12. The inferior side of vertical sections of optical coherence tomography is depicted on the left side of figures.

Figure 3

White depigmented eyelashes in the right eye (A) and left eye (B), with mascara, in July 2015. Intraocular inflammation in the anterior segment of the right eye (C) and left eye (D), presenting as mutton‐fat keratic precipitates and white iris nodules along the pupillary margin (arrows) in April 2016, two months after 0.1% betamethasone eye drops have been discontinued due to steroid‐induced intraocular pressure elevation. The right eye only has intraocular lens implantation. She also shows red depigmented fundus in the right eye (E) and left eye (F).