1370. Concurrent Anti-PD -1 and Anti-tubercular Therapy in a Patient with Refractory Lymphoma and Pulmonary Tuberculosis: A Case Report

Abstract

Backgroundsafety and efficacy of concurrent treatment for tuberculosis and checkpoint inhibitor drugs are unknown.Methodscase report.Results36-year-old gentleman presented with bulky adenopathy in December 2016. Work-up revealed classical Hodgkin’s lymphoma with extra-nodal sites of involvement including bone, lungs and skeletal muscle. After his disease proved refractory to the standard first and second-line treatments, complete remission was achieved with anti-CD 30 drug-toxin conjugate, brentuximab followed by consolidation with autologous stem cell transplant in February 2018. However, his lymphoma recurred in June 2018 with new bulky adenopathy and new bilateral nodular pulmonary infiltrates. PET imaging revealed multiple avid lymph nodes, liver and bone lesions. Biopsy of a neck node confirmed relapsed lymphoma. Cultures of sputa revealed drug-susceptible M. tuberculosis. Four drug treatment with Isoniazid, Rifampin, Ethambutol and Pyrazinamide was initiated in June 2018. Hospice enrollment was considered because of progressive lymphoma and poor functional status. In July 2018, patient elected for a trial of salvage treatment with Nivolumab, a PD-1 checkpoint inhibitor (CPI) while on anti-tubercular treatment. He was monitored for paradoxical worsening of symptoms. He tolerated the tuberculosis medications well for the entire 6-month course, follow-up sputa were culture negative. His lymphoma remains in remission on maintenance nivolumab as a donor search is underway.ConclusionAuto-immune reactions and immune-related adverse events are major side effects of CPI drugs. Our understanding of the interplay between checkpoint inhibitors and infectious risks continues to evolve. Among the few cases reported in the literature, patients on CPIs have experienced both reactivation of latent tuberculosis as well as severe, fatal paradoxical reactions during treatment of active tuberculosis. Despite the relatively uncomplicated course in our patient, tuberculosis in this group of patients poses many challenges in diagnosis and management and warrants close monitoring and follow-up.Disclosures All authors: No reported disclosures.