BackgroundTo date, patients with pre-existing autoimmune conditions have been excluded from immunotherapy trials out of concern for severe autoimmune exacerbations.Case PresentationWe describe the first case of a patient with metastatic cKIT mutated acral melanoma, brain metastasis, and pre-existing severe autoimmune bullous pemphigoid (BP) with stable and asymptomatic disease 10 months after treatment with pembrolizumab. The patient experienced severe BP exacerbation after therapy with ipilimumab requiring systemic immune suppression, but nonetheless pembrolizumab was administered on further disease progression.ConclusionsThis case suggests that pembrolizumab may confer more benefit than risk even in patients with known severe autoimmune conditions who require intermittent systemic immunosuppression.
A 73-year-old white man presented to our dermatology service in 1982 with a 40-year history of psoriasis. His medical history was significant for hypertension, which was managed with propranolol and furosemide. He was also treated with indomethacin for arthritis. Prior treatment for psoriasis included only topical corticosteroids and emollients, and this regimen failed ultimately to manage his disease adequately. It was decided to begin the Goeckerman regimen, and this patient's psoriasis rapidly cleared. Over the ensuing years, UV-B therapy was used sporadically for maintenance.In November 1985, a solitary pigmented nail streak was noted for the first time on the left index finger. A 2-mm punch biopsy specimen of the nail matrix revealed a subungual melanoma, and a matricectomy was subsequently performed (Fig 1). Healing occurred without complication.In July 1986, the patient experienced a flare of his psoriasis, and phototherapy was restarted. A new pigmented nail streak was then noted on the right second finger. A biopsy specimen of this nail streak was obtained, and examination of the histologie findings revealed benign melanocytic hyperplasia. Frequent follow-up failed to reveal additional Fig 1.-Histologie section from nail matrix (hematoxylin-eosin, X40). Note increase in confluent large pale-staining melanocytes that do not form discrete nests.Fig 2.-An example of the multiple pigmented toenail streaks.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.