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Diffuse alveolar hemorrhage with nivolumab monotherapy.

ABSTRACT: We describe a 60 year old man who developed respiratory insufficiency after treatment with 2 rounds of nivolumab monotherapy. Imaging revealed subtle ground glass infiltrates which progressed to diffuse opacities and consolidation. The patient was treated with high dose corticosteroids, empiric antimicrobial therapy and infliximab. Bronchoscopy with lavage revealed negative cultures and progressive bloody aliquots of fluid consistent with diffuse alveolar hemorrhage. The patient succumbed to respiratory failure. An autopsy study confirmed extensive alveolar hemorrhage. Our reports highlights clinical and diagnostic findings with immunotherapy-induced pneumonitis.

SUBMITTER: Shannon VR

PROVIDER: S-EPMC7303994 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Diffuse alveolar hemorrhage with nivolumab monotherapy.

Shannon Vickie R VR Subudhi Sumit K SK Huo Lei L Faiz Saadia A SA

Respiratory medicine case reports 20200611

We describe a 60 year old man who developed respiratory insufficiency after treatment with 2 rounds of nivolumab monotherapy. Imaging revealed subtle ground glass infiltrates which progressed to diffuse opacities and consolidation. The patient was treated with high dose corticosteroids, empiric antimicrobial therapy and infliximab. Bronchoscopy with lavage revealed negative cultures and progressive bloody aliquots of fluid consistent with diffuse alveolar hemorrhage. The patient succumbed to res ...[more]

PMID: 32577370

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Project description:Diffuse alveolar hemorrhage (DAH) can be caused by various conditions, categorized as autoimmune and non-autoimmune. Immunofactor-mediated vasculitis, such as Wegener granulomatosis, microscopic polyangiitis, Goodpasture syndrome, connective tissue disorders, and antiphospholipid antibody syndrome, are common autoimmune causes. Non-autoimmune factors include infectious or toxic exposures and neoplastic conditions. The diagnosis of DAH, resulting from excessive catecholamine release from an adrenal pheochromocytoma or extra-adrenal paraganglioma, can present diagnostic challenges and necessitate prompt treatment. In this report, we present a case of pheochromocytoma that manifested as an adrenal incidentaloma (diagnosed during the management of sudden-onset DAH after cholecystectomy). Case report: A 39-year-old female patient with adrenal incidentaloma developed DAH following a cholecystectomy procedure, presenting with sudden-onset hemoptysis and dyspnea. Administration of glucocorticoids, known to precipitate pheochromocytoma crisis (PCC), was required before the cause was determined. Intubation and mechanical ventilation were necessary due to persistent hypoxemic respiratory failure and acute respiratory distress syndrome (ARDS). The patient in this case experienced two epidoses of PCC while she was on mechanical ventilation. Subsequent work-up revealed a 26 × 25 mm left adrenal adenoma with hormonal confirmation of catecholamine hypersecretion. A laparoscopic adrenalectomy was done eight months later to excise the left adrenal gland. Subsequent examination of the tissue revealed pheochromocytoma, thereby validating the initial diagnosis. Conclusion: Adrenal incidentalomas may be pheochromocytomas (adrenal incidentalomas can manifest as pheochromocytomas), even without adrenergic symptoms. It is recommended that adrenal incidentalomas undergo evaluation for pheochromocytoma before undergoing invasive surgery or receiving corticosteroid treatment. When considering potential causes of DAH without further elucidation, including a pheochromocytoma or paraganglioma (PPGLs) in the differential diagnosis is important.

Dataset Information

Diffuse alveolar hemorrhage with nivolumab monotherapy.

Publications

Diffuse alveolar hemorrhage with nivolumab monotherapy.

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