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Case Reports
. 2018 Feb 12;6(1):12.
doi: 10.1186/s40425-018-0321-2.

Ipilimumab induced digital vasculitis

Amrita Padda  1 , Elena Schiopu  2 , Justin Sovich  3 , Vincent Ma  3 , Ajjai Alva  4 , Leslie Fecher  4
Affiliations
Case Reports

Ipilimumab induced digital vasculitis

Amrita Padda et al. J Immunother Cancer. .

Abstract

Background: Immune check point inhibitors (ICIs) have emerged as a new therapeutic paradigm for a variety of malignancies including metastatic melanoma. As the use of ICIs expand, immune-mediated adverse events are becoming a common occurrence.

Case presentation: We describe the first reported patient with small vessel vasculitis, manifested by digital ischemia, following treatment with high dose Ipilimumab for resected stage IIIB/C melanoma. This patient received high dose steroids, five-day intravenous (IV) Epoprostenol protocol, botulinum toxin injections, and Rituximab 375 mg/m2 weekly for four cycles. With this treatment regimen, the digital ischemia did not progress proximally, but she did require multiple distal digit amputations about six months after the onset of her symptoms.

Conclusions: Prompt identification and management of immune related adverse events (IRAEs) are critical to optimal patient management. This patient's vasculitis did not reverse, but was likely halted and stabilized with multiple immunosuppressive medications.

Keywords: Immune related adverse events (IRAEs); Ipilimumab; Vasculitis.

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Conflict of interest statement

Ethics approval and consent to participate

No formal ethics approval was needed since we were only reporting an observational case report. Consent was obtained from the patient.

Consent for publication

Consent was obtained from the patient. She signed a biomed generic consent for this journal.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
(Panel a and b). This picture was taken four weeks after her second Ipilimumab infusion (week 26 on timeline). Physical exam reveals acrocyanosis of all digits with small ulcers of the right second and fourth fingertips
Fig. 2
Fig. 2
Conventional angiogram of the left arm was performed five weeks after her second Ipilimumab infusion (end of week 26 on timeline). There is severely diminished flow in the digital arteries of the left hand beyond the level of all proximal interphalangeal joints (black arrow), consistent with small vessel occlusive disease
Fig. 3
Fig. 3
(Panel a and b) This picture was taken nine weeks after her second Ipilimumab infusion (week 31 on timeline). The patient is status-post high dose steroids and four cycles of Rituximab. The exam appeared worse with dry gangrene of the fingertips, secondary to the natural evolution of skin changes with distal digital ischemia. We believe that the vasculitic process was halted, as she did not develop further proximal digital ischemia
See this image and copyright information in PMC

Comment in

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