Immune-related (IR)-pneumonitis during the COVID-19 pandemic: multidisciplinary recommendations for diagnosis and management

Abstract

Immune-related (IR)-pneumonitis is a rare and potentially fatal toxicity of anti-PD(L)1 immunotherapy. Expert guidelines for the diagnosis and management of IR-pneumonitis include multidisciplinary input from medical oncology, pulmonary medicine, infectious disease, and radiology specialists. Severe acute respiratory syndrome coronavirus 2 is a recently recognized respiratory virus that is responsible for causing the COVID-19 global pandemic. Symptoms and imaging findings from IR-pneumonitis and COVID-19 pneumonia can be similar, and early COVID-19 viral testing may yield false negative results, complicating the diagnosis and management of both entities. Herein, we present a set of multidisciplinary consensus recommendations for the diagnosis and management of IR-pneumonitis in the setting of COVID-19 including: (1) isolation procedures, (2) recommended imaging and interpretation, (3) adaptations to invasive testing, (4) adaptations to the management of IR-pneumonitis, (5) immunosuppression for steroid-refractory IR-pneumonitis, and (6) management of suspected concurrent IR-pneumonitis and COVID-19 infection. There is an emerging need for the adaptation of expert guidelines for IR-pneumonitis in the setting of the global COVID-19 pandemic. We propose a multidisciplinary consensus on this topic, in this position paper.

Keywords: autoimmunity; guidelines as topic; immunotherapy.

Figure 1

Representative images for COVID-19 (A–D) and immune-related (IR) pneumonitis (E–H). (A) Radiograph with opacities in bilateral upper and mid-lung fields. (B) Axial chest CT with diffuse bilateral ground-glass opacities (GGOs) with areas of consolidative opacities. (C) Axial chest CT with predominantly peripheral GGOs associated with interlobular septal thickening. (D) Axial chest CT with bilateral peripheral interstitial opacities with GGOs, reticular opacities, consolidation and interlobular septal thickening. (E) Radiograph of patient with immune-related pneumonitis, demonstrating left upper lobe predominant airspace opacities. (F) Axial chest CT of same patient demonstrates bilateral GGOs with interlobular septal thickening. (G) Axial chest CT demonstrating cryptogenic organizing pneumonia pattern of IR-pneumonitis with multifocal discrete areas of consolidation and bilateral GGOs. (H) Axial chest CT demonstrating a non-specific interstitial pneumonia pattern of IR-pneumonitis with increased interstitial markings, interlobular septal thickening, subpleural GGOs and reticular opacities. (A–D) images abstracted from Zu et al, Shi et al (E–F) images abstracted fromNaidoo et al, Al-Shamsi et al, Licenses to reproduce images obtained for and, licenses for and in process.