PERIBRONCHOVASCULAR RING-SHAPED OPACITIES AS AN UNUSUAL PRESENTATION OF NIVOLUMAB-INDUCED ILD: A VASCULAR HALO SIGN?

Abstract

SESSION TITLE: Imaging SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Pneumonitis associated to anti-programmed cell death receptor 1 drugs is being recognized more frequently as their use is being extended into different types of cancer(1). An uncommon but severe complication is the development of pneumonitis(2-3). A third of the patients do not have a specific radiolographic pattern and represent a challenge in diagnosis and management as their radiographical characteristic might require further invasive work up and can resemble atypical or fungal infections. CASE PRESENTATION: We present a 35-year-old female with history of Hodgkin’s lymphoma who presented with a mild, dry cough for 2 months. She had failed 3 prior treatments for her lymphoma and had been started on nivolumab 3 months before presentation. She denied any shortness of breath, wheezing, chills or fevers and stated that she only noticed a mild cough. She was able to ambulate and perform regular activities without any problems and denied any recent travels, sick contacts or animal exposure. Her physical exam was unremarkable. Her only medication was dextroamphetamine (Adderall) that she has been taking for years. Laboratory tests including white blood cell count and complete metabolic panel were unchanged from prior visits. A chest computed tomography scan showed bilateral ground-glass opacities and multiple areas of peribronchovascular “ring-like” opacities with normal lung parenchyma in the center (figure 1A, 2A, and 3A). Her pulmonary function testing revealed mild decrease in gas exchange (diffuse capacity of the lung for carbon monoxide decreased from 82% to 66% within the past year). Blood cultures and sputum cultures were not taken because of the absence of fevers and other infectious symptoms. Further testing including a bronchoscopy with lung biopsies was withheld following discussions with oncology. Nivolumab was stopped and subsequent CT of the chest was repeated a month later. She was not given steroids given her mild symptoms. Significant radiological improvement was seen and the cough resolved (figure 1B, 2B, and 3B). Additional slides of both the lung CT at presentation and follow-up are available in supplemental material. DISCUSSION: To our knowledge, this is the first case in the literature that reports an imaging finding that looks like a halo around the peribronchial vasculature. Our patient did not get a lung biopsy so we cannot definitely state that it represents a case of OP. However, the opacities possibly represented inflammation caused by nivolumab as they improved after withholding the drug. CONCLUSIONS: The clinical and radiological improvement of our patient adds to the evidence that withholding nivolumab and avoiding invasive procedures can be an appropriate treatment for the management of patients with mild symptoms. This is the first report of a vascular sign associated with pneumonitis but more studies are needed to better define this atypical presentation. Reference #1: Johnson DB, Peng C, Sosman JA. Nivolumab in melanoma: latest evidence and clinical potential. Therapeutic advances in medical oncology. 2015;7(2):97-106. Reference #2: Sundar R, Cho BC, Brahmer JR, Soo RA. Nivolumab in NSCLC: latest evidence and clinical potential. Therapeutic advances in medical oncology. 2015;7(2):85-96. Reference #3: Delaunay M, Cadranel J, Lusque A, Meyer N, Gounant V, Moro-Sibilot D, et al. Immune-checkpoint inhibitors associated with interstitial lung disease in cancer patients. The European respiratory journal. 2017;50(2). DISCLOSURES: No relevant relationships by Julio Huapaya, source=Web Response No relevant relationships by Christopher Wyckoff, source=Web Response