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Case Reports
. 2021 Dec 9:11:749834.
doi: 10.3389/fonc.2021.749834. eCollection 2021.

Immune Checkpoint Inhibitor Induced Pericarditis and Encephalitis in a Patient Treated With Ipilimumab and Nivolumab for Metastatic Melanoma: A Case Report and Review of the Literature

Jorja Braden  1 , Jenny H Lee  1   2
Affiliations
Case Reports

Immune Checkpoint Inhibitor Induced Pericarditis and Encephalitis in a Patient Treated With Ipilimumab and Nivolumab for Metastatic Melanoma: A Case Report and Review of the Literature

Jorja Braden et al. Front Oncol. .

Abstract

Immune checkpoint inhibitors (ICIs) have dramatically improved outcomes in melanoma. Common ICI toxicities have become familiar to clinicians; however, rare delayed toxicities remain challenging given the paucity of data with such presentations. We present the unique case of a 61-year-old with metastatic melanoma with two rare, delayed ICI-induced toxicities. After resection of a large symptomatic parietal metastases, this patient received two doses of combination ipilimumab and nivolumab. Five weeks following his second dose, he developed ICI-induced pericarditis with associated pericardial effusion and early signs of tamponade. Corticosteroids were not administered due to a concurrent cerebral abscess. Administration of colchicine, ibuprofen, judicious monitoring, and cessation of immunotherapy led to the complete resolution of the effusion over several weeks. Seven months following his last dose of immunotherapy, the patient developed ICI-associated grade four autoimmune encephalitis, presenting as status epilepticus. High-dose steroid initiation led to rapid clinical improvement. The patient remains in near-complete response on imaging with no recurrence of pericardial effusion and partial resolution of neurological symptoms. ICI-induced pericardial disease and encephalitis carry substantial mortality rates and prompt diagnosis and management is critical. Clinicians must therefore remain vigilant for these rare toxicities regardless of duration of drug exposure or time since cessation of therapy.

Keywords: delayed immune reaction; encephalitis; immune-related adverse effects; immunotherapy; melanoma; pericarditis.

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Conflict of interest statement

JL is on the advisory board for Sanofi and has received honorarium from MSD, BMS, Novartis and travel support from BioRad. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Timeline of case report of patient with rare delayed immune-related toxicities. (A) February 14, 2020, first brain metastasis resection. (B) March 2020, first cycle ipilimumab/nivolumab. (C) April 4, second cycle ipilimumab/nivolumab. (D) April 8, second brain metastasis resection. (E) May 12, presentation with immune-related pericarditis. (F) June 24, third brain metastasis resection. (G) July 14, stereotactic radiosurgery of resection cavity. (H) Presentation with auto-immune encephalitis.
Figure 2
Figure 2
Serial MRI brain showing development of encephalitis and serial PET/CT demonstrating the patient’s durable response to immunotherapy. (A) MRI brain with gadolinium Sept 2, 2020—no abnormalities in medial temporal region. (B) MRI brain October 29, 2020 shows new T2/FLAIR hyperintensity in the right medial temporal lobes. (C) PET/CT March 2020. (D) PET CT March 2021.
See this image and copyright information in PMC

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