DURVALUMAB-INDUCED PNEUMONITIS IN A PATIENT WITH RHEUMATOID ARTHRITIS-INTERSTITIAL LUNG DISEASE

Abstract

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Immune check point inhibitors (CPIs) are now widely used for different malignancies. Patients with autoimmune diseases, have been excluded from the CPIs clinical trials due to concerns of worsening of their autoimmune disease. Thus, the evidence regarding the toxicity of CPIs in this population is limited. Durvalumab, a CPI, is anti-programmed death ligand 1 (PD-L1) monoclonal antibody. We present a case of durvalumab induced pneumonitis in a patient with Rheumatoid arthritis related interstitial lung disease (RA-ILD). CASE PRESENTATION: A 63-year man with active seropositive RA with ILD treated with methotrexate 15 mg/week. He was recently diagnosed with stage IIIB lung adenocarcinoma. He was treated with platinum-based chemo-radiotherapy but developed severe fatigue and was given a treatment-free interval. Decision was made afterwards to administer durvalumab. Four days after infusion, patient had severe dyspnea, dry cough and chest pain requiring hospitalization. His oxygen requirements increased from room air oxygen to 8 L via nasal cannula. Patient was afebrile and labs were significant for normal WBC count, procalcitonin level, negative nasal swab for influenza antigen and respiratory viral panel. Blood and sputum cultures remained negative. A computerized tomography of the chest (CT) , compared to a previous CT, showed new diffuse upper-lobe predominant ground glass opacities with background ILD findings (figure 1). Durvalumab was held and patient was initially treated with empiric antibiotics that was stopped later with negative infectious work up. Patient was diagnosed with grade 4 immune pneumonitis and he was started on intravenous (IV) methylprednisolone (2 mg/kg) tapered down to 60 mg prednisone over 5 weeks with minimal clinical improvement. We decided to treat him again with IV methylprednisolone (250 mg) for 3 days and to add infliximab infusion (500 mg infusion). Over the next 10 days, patient improved clinically with decreasing oxygen requirements and plan was to discharge him to finish a slow steroids taper over 32 weeks with outpatient follow up. DISCUSSION: We describe a case of active RA who was treated with durvalumab for his lung cancer. In our case, patient was steroid-refractory initially but showed clinical improvement after giving another pulse dose steroids with infliximab infusion. Pneumonitis is uncommon immune related toxicity of CPIs but can be fatal. Incidence was reported to be 5% in one report. Our case is important as it describes severe pneumonitis in a patient with underlying RA-ILD who showed a promising response to steroid and infliximab. CONCLUSIONS: Immune mediated toxicities of CPIs, can be life threatening. More studies are needed to clarify whether a pre-existing autoimmune disease pose a higher risk of these adverse events. Clinicians should only start CPIs after having full discussion with their patients about the potential risks and benefits. Reference #1: 1. Review AS. R EVIEW Use of Immune Checkpoint Inhibitors in the Treatment of Patients With Cancer and Preexisting Autoimmune Disease. 2018. https://doi.org/10.7326/M17-2073 Reference #2: 2. Yamaguchi S, Ito S, Akaike K, et al. A case report of using nivolumab for a malignant melanoma patient with rheumatoid arthritis. Int Cancer Conf J. 2016;5(4):192-196. https://doi.org/10.1007/s13691-016-0256-8 Reference #3: 3. Leduc C, Menzies AM, Iyriboz T, et al. Pneumonitis in Patients Treated With Anti–Programmed Death-1/Programmed Death Ligand 1 Therapy. J Clin Oncol. 2016;35(7):709-717. https://doi.org/10.1200/jco.2016.68.2005 DISCLOSURES: No relevant relationships by bashar alzghoul, source=Web Response No relevant relationships by Runi Foster, source=Web Response No relevant relationships by Wissam Hanayneh, source=Web Response No relevant relationships by Saminder Kalra, source=Web Response