A Case Report of Steroid Responsive Nivolumab-Induced Encephalitis

Abstract

Nivolumab (Opdivo) approval for the treatment of non-small cell lung cancer (NSCLC) prompts recognition of its future use in various cancers. Although rare, occurring in 1% to 3% of treated cases, nivolumab along with other immune checkpoint inhibitors are associated with immune-related encephalitis. With its prospective use, nivolumab-induced encephalitis illustrates the necessity of early recognition and successful management to decrease morbidity and mortality. We describe a treated case of nivolumab-induced encephalitis. A 74-year-old male with a history of stage 4 squamous NSCLC presenting with insidious altered mental status following his first dose of nivolumab. After an extensive workup that proved negative, the patient received intravenous steroids with gradual improvement of mental status. Patient subsequently returned to baseline and was discharged with oral steroid taper. Nivolumab-induced encephalitis is a diagnosis of exclusion with nonspecific signs and symptoms. Immediate recognition of patients prescribed nivolumab chemotherapy could potentially prevent fatal complications of neurotoxicity.

New therapeutic perspectives to manage refractory immune checkpoint-related toxicities

“…15 As the treatment backbone of GBS relies on the latter, corticosteroid-refractory immune-related AIDP and/or encephalitis patients could be considered as potential candidates for plasmapharesis. 76…”

Very high-dose methylprednisolone for treatment of nivolumab-induced limbic encephalitis: A case report

“…14 Nivolumab's action as PD-1 receptor inhibitor interferes with T-cell inactivation, counteracting T-cell exhaustion. 15 This interference with lymphocyte regulation stimulates antitumor response. It also increases the risk of autoimmune drug-mediated reactions through inflammatory infiltration of solid organs and increased cytokine release disturbing normal cellular function.…”

“…It also increases the risk of autoimmune drug-mediated reactions through inflammatory infiltration of solid organs and increased cytokine release disturbing normal cellular function. [15][16][17] It has been hypothesized that the presence of specific autoantibodies for paraneoplastic syndromes, such as anti-Hu, anti-Ma/Ta and anti-NMDA antibodies, may be associated with a higher risk of developing autoimmune adverse effects with immune checkpoint inhibitors. [15][16][17] Our patient suffered from pre-morbid autoimmune conditions (vitiligo) and presented nivolumab-related autoimmune thyroidopathy with mildly positive anti-TPO antibodies before the onset of limbic encephalitis.…”

“…[15][16][17] It has been hypothesized that the presence of specific autoantibodies for paraneoplastic syndromes, such as anti-Hu, anti-Ma/Ta and anti-NMDA antibodies, may be associated with a higher risk of developing autoimmune adverse effects with immune checkpoint inhibitors. [15][16][17] Our patient suffered from pre-morbid autoimmune conditions (vitiligo) and presented nivolumab-related autoimmune thyroidopathy with mildly positive anti-TPO antibodies before the onset of limbic encephalitis. Encephalopathy associated with autoimmune thyroid disease, exacerbated by nivolumab, could therefore have contributed to the clinical presentation in our patient, although normal TSH and mild anti-TPO antibodies titers are not in favor of this controversial entity.…”

Varicella Zoster Virus Encephalitis Mimicking Nivolumab-Induced Autoimmune Neuropathy in a Patient with Lung Cancer

“…Autoimmune encephalitis is a rare but severe immunerelated adverse event induced by immune checkpoint inhibitors (ICIs) ( Table 2). [1][2][3][4][5][6][7][8][9][10] Diagnosis of this condition is challenging, as symptoms frequently mimic those of encephalopathy of tumor metastatic, paraneoplastic, or infectious origin. ICI-related infectious complications have been rarely reported.…”