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Case Reports
. 2020 Apr 15;59(8):1075-1080.
doi: 10.2169/internalmedicine.3889-19. Epub 2020 Feb 1.

Hemophagocytic Lymphohistiocytosis in a Patient with Rheumatoid Arthritis on Pembrolizumab for Lung Adenocarcinoma

Yu Akagi  1 , Nobuyasu Awano  1 , Minoru Inomata  1 , Naoyuki Kuse  1 , Mari Tone  1 , Hanako Yoshimura  1 , Tatsunori Jo  1 , Kohei Takada  1 , Toshio Kumasaka  2 , Takehiro Izumo  1
Affiliations
Case Reports

Hemophagocytic Lymphohistiocytosis in a Patient with Rheumatoid Arthritis on Pembrolizumab for Lung Adenocarcinoma

Yu Akagi et al. Intern Med. .

Abstract

Immune checkpoint inhibitors have changed the landscape of classic cancer treatment. However, their use is associated with the emergence of new adverse events. An elderly man with rheumatoid arthritis was started on pembrolizumab for newly diagnosed advanced lung cancer. He subsequently developed hemophagocytic lymphohistiocytosis (HLH), which is potentially fatal but has not been properly established as an immune checkpoint inhibition-induced event. We herein report the case of a patient with pembrolizumab-induced HLH.

Keywords: hemophagocytic lymphohistiocytosis; immune checkpoint inhibitors; immune-related adverse event; lung cancer; pembrolizumab; rheumatoid arthritis.

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Conflict of interest statement

The authors state that they have no Conflict of Interest (COI).

Figures

Figure 1.
Figure 1.
Changes in CT findings. The upper panels show the liver and spleen: (a) No abnormal liver or spleen findings were seen before admission. (d) Hepatosplenomegaly was detected on admission. (g) The liver and spleen sizes normalized before discharge. The middle panels show the inferior tracheobronchial lymph nodes (white arrows): (b) An enlarged lymph node was confirmed before admission. (e) The lymph node had appeared smaller on admission. (h) The lymph node had nearly normalized in size before discharge. The lower panels show the lung tumor in the right lower lobe (black arrow heads): (c) A lung nodule was seen before admission. (f) The lung nodule appeared smaller on admission. (i) The nodule had significantly decreased in diameter before discharge.
Figure 2.
Figure 2.
Biopsy specimen. (a) The bone marrow biopsy, Hematoxylin and Eosin (H&E) staining, 400× magnification. The black arrowhead points to an erythrocyte-phagocytosing macrophage. (b) Perivascular lymphocyte infiltration confirmed by a skin biopsy, H&E staining, 400× magnification.
Figure 3.
Figure 3.
Physical findings. Macular rash observed on the forearm.
Figure 4.
Figure 4.
The patient’s clinical course. Continuous and dashed lines indicate the white cell counts and ferritin levels, respectively. The patient developed febrile neutropenia on the 15th hospital day and was discharged on the 33rd hospital day. CFPM: cefepime, CMZ: cefmetazole, G-CSF: granulocyte colony-stimulating factor, mPSL: methylprednisolone, rTM: recombinant thrombomodulin
See this image and copyright information in PMC

References

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