Emerging Side Effects of Programmed Cell Death 1 Ligand Inhibitors: MAC Infection and Nivolumab

Abstract

SESSION TITLE: Non-Small Cell Lung Cancer SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Mycobacterium Avium Complex (MAC) is a ubiquitous environmental microorganism. In recent years, there has been an increase in disease incidence; it is not clear whether this reflects a real increase in infection rate or greater recognition resulting from more widespread awareness and advanced laboratory techniques. A potential reason for the MAC infection is the weakened immune system in aging population and the rise in the use of immunomodulating drugs. We hereby describe the first known case report of MAC infection in a patient with Non-Small Cell Lung Cancer (NSCLC) receiving Nivolumab (Opdivo) a programmed cell death 1 ligand inhibitor. CASE PRESENTATION: Our patient is an 83 years old gentleman with lung adenocarcinoma diagnosed in June 2011. He had received six cycles of Pemetrexed and Carboplatin and placed on maintenance therapy with Pemetrexed which was discontinued due side effects. The cancer progressed and the patient was placed on Opdivo with great response. At a follow up appointment, the patient presented with progressive fatigue, weight loss, and dry cough. On physical examination, the patient appeared chronically ill, with no specific respiratory exam findings. His chest was clear to auscultation without wheezing, rhonchi or crackles. Additionally, his laboratory results showed normal WBC count and differential. CT scan of the chest showed no progression of his cancer but revealed new nodular and small cavitary lesions with centrilobular nodularity in tree-in-bud distribution (figure 1). Subsequently the patient underwent bronchoscopy with diagnostic bronchoalveolar lavage which returned positive for MAI infection. The patient was placed on triple antibiotics and the Opdivo was placed on hold. At three months follow up, the patient showed significant improvement in his fatigue and weight and his cough had resolved. DISCUSSION: Despite the impressive benefits of the immune checkpoint blockade, its use can be hampered by the occurrence of serious adverse events including immune-related adverse events (irAEs) and opportunistic infections with potentially aggressive course and fatal outcome. With more indications and widespread use of these medications we will be encountering more of their side effects. Prompt diagnosis, discontinuation of the drug and starting antibiotics treatment is the key for successful treatment CONCLUSIONS: It is important to become aware of the possible infections that patient on current treatment with Opdivo (Nivolumab) could develop; it becomes important to keep in mind that MAC infections should be at the top of the list in the differential diagnosis if patient presents with symptoms such as cough, fever, severe fatigue. Reference #1: OPDIVO. Package insert. Princeton, NJ: Bristol Myers Squibb Company; 2016. DISCLOSURE: The following authors have nothing to disclose: Fernando Fuentes, Yousef Al-ahwel No Product/Research Disclosure Information