Immune checkpoint inhibitor therapy related pneumonitis
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Immune checkpoint inhibitor therapy-related pneumonitis is one of the complications that can occur in the setting of immune checkpoint inhibitor therapy.
Immune checkpoint inhibitor therapy-related pneumonitis is considered a rare complication with a reported incidence of <5% in monotherapy and slightly higher than 5% in combination therapy 1.
The median timing of onset is 2.5 months after initiation of the immune checkpoint inhibitor therapy, although there is a wide range (2-24 months) 2.
Patients often complain of cough and dyspnea and may quickly progress to hypoxia and respiratory failure 3,4. Fever and chest pain are less common.
It is important to emphasize that not all patients with immune checkpoint inhibitor therapy-related pneumonitis are symptomatic and CT may detect it before any clinical symptoms start to be evident 5. Therefore, it is critical to recognize this complication in any patient under treatment with immune checkpoint inhibitors even without symptoms.
Variable and several distinct radiographic patterns of pneumonitis have been described which include 5:
- organizing pneumonia pattern
- non-specific interstitial pneumonia (NSIP) pattern
- hypersensitivity pneumonitis pattern
- acute interstitial pneumonia / acute respiratory distress syndrome pattern
- radiation recall pneumonitis
Treatment and prognosis
Treatment of immune checkpoint inhibitor therapy-related pneumonitis varies according to the severity of pneumonia quantified by a grading ranging from 1 (mildest) to 5 (death) described in Common Terminology Criteria for Adverse Events (CTCAE).
In grade 1 (radiologic changes without symptoms), it is recommended to clinically monitor the patient for 2-3 days and repeat imaging every 3 weeks 7. In the other cases, the treatment is essentially based on the administration of steroids. In the most severe cases requiring admission to hospital or ICU, other immunosuppressors such as intravenous immunoglobulin (IVIG), infliximab, cyclophosphamide and mycophenolate mofetil can be used 4.
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