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Case Report
Immunotherapy-mediated encephalitis in an oncological patient
1 Assistant Member, Department of Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, Florida, USA
2 Lead APP Supervisor, Department of Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, Florida, USA
3 Assistant Member, Department of Neuro-Oncology and Neurosurgery, Moffitt Cancer Center, Tampa, Florida, USA
Address correspondence to:
Dinesh Keerty
Department of Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, Florida 33612,
USA
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Article ID: 101124Z01DK2020
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Keerty D, Grenier M, Peguero E, Holmstrom B. Immunotherapy-mediated encephalitis in an oncological patient. Int J Case Rep Images 2020;11:101124Z01DK2020.ABSTRACT
Introduction: Autoimmune encephalitis causes subacute deficits of memory and cognition, often followed by suppressed level of consciousness or coma. Checkpoint inhibition is the mainstay of treatment in metastatic melanoma. More recently combination of cytotoxic T-lymphocyte antigen-4 (CTLA-4) and programmed-death-1 (PD-1) blockade has resulted in improved response rates and overall survival in treatment naïve patients. Neurological toxicities are an emerging consequence of the use of checkpoint inhibitors. We are here to present a case of neurotoxicity from the use of immunotherapy.
Case Report: A 63-year-old female with metastatic melanoma to brain and breast presented to the emergency department with altered mental status. She was disoriented to time and place and unable to follow commands. She had received two doses of immunotherapy with ipilimumab and nivolumab. Her last dose was administered two weeks prior. She developed low grade fever and fatigue over the past week prompting evaluation by her local oncologist who prescribed her sulfamethoxazole-trimethoprim for possible urinary tract infection. She never picked up the prescription and two days later she went to an urgent care for worsening lethargy and fever. An infectious workup was negative. She presented to our emergency department with incoherent speech and inability to comprehend. Infectious workup was again negative. Her labs were unremarkable except for hyponatremia with sodium of 123 mmol/L. A computed tomography (CT) scan of the head was negative. Magnetic resonance imaging (MRI) of the brain was done and the report did not show the previously noted brain lesions. Neurology was consulted and an electroencephalography (EEG) was done showing frequent temporal intermittent rhythmic activity (TIRDA) in the right hemisphere consistent with a tendency for seizures. There were no ictal discharges but EEG did show moderate diffuse nonspecific encephalopathy. Lumbar puncture was negative for any viral etiologies such as herpes simplex along with cell counts that were in normal range. She was started on levetiracetam and methylprednisolone 2 mg/kg daily. Within 24 hours of initiating steroids and prior to her sodium correcting, she became alert and oriented with improved ability to follow commands. After 48 hours of steroids and antiepileptic treatment, a repeat EEG was done which showed no abnormal activity. She was monitored for four more days in hospital with eventual return to her baseline.
Conclusion: Counseling patients receiving immunotherapy to report any new symptoms promptly is imperative as early identification of immune-mediated adverse events leads to better outcomes. Providers should have a high index of suspicion for immune-mediated adverse events in all patients on immunotherapy presenting with new symptoms. Early identification of an immune-mediated adverse event is crucial for better patient outcomes.
Keywords: Adverse events, Encephalitis, Immunotherapy, Melanoma
SUPPORTING INFORMATION
Author Contributions
Dinesh Keerty - Substantial contributions to conception and design, Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Marlene Grenier - Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Edwin Peguero - Interpretation of data, Final approval of the version to be published
Bjorn Holmstrom - Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Guaranter of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone
Consent StatementWritten informed consent was obtained from the patient for publication of this article.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
Conflict of InterestAuthors declare no conflict of interest.
Copyright© 2020 Dinesh Keerty et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.
