A case of dual-mechanism immune-related anaemia in a patient with metastatic melanoma treated with nivolumab and ipilimumab
Open Access
- 20 December 2019
- journal article
- research article
- Published by BMJ in Journal for ImmunoTherapy of Cancer
- Vol. 8 (1), e000380
- https://doi.org/10.1136/jitc-2019-000380
Abstract
Background The combination of the immune checkpoint inhibitors (ICIs) ipilimumab and nivolumab is a mainstay of treatment for selected patients with metastatic melanoma. This combination also results in more frequent immune-related adverse events (irAEs) than either ICI alone. These irAEs can be severe and their pathogenesis is poorly understood. Case presentation We report a case of a woman with metastatic melanoma, treated with combined ipilimumab and nivolumab, who developed severe anaemia. While initial workup revealed autoimmune haemolytic anaemia, the anaemia persisted despite corticosteroids and paradoxical reticulocytopenia was observed. Bone marrow biopsy demonstrated a CD8+ T cell-mediated destruction of the red cell precursors implying concurrent pure red cell aplasia. Both processes resolved after the addition of cyclosporine A. Conclusions This report describes a rare case of two concurrent mechanisms of haematological irAE in a patient treated with combined ICI therapy. Successful treatment resulted only after the second underlying mechanism of toxicity was uncovered. Prompt recognition of these unusual presentations of rare irAEs is now key to effective irAE management.Funding Information
- Clinical Therapeutics Training Grant (T32GM007019)
This publication has 27 references indexed in Scilit:
- Overall Survival with Combined Nivolumab and Ipilimumab in Advanced MelanomaThe New England Journal of Medicine, 2017
- Open vascular treatment of median arcuate ligament syndromeBMC Surgery, 2017
- Myasthenia triggered by immune checkpoint inhibitors: New case and literature reviewNeuromuscular Disorders, 2017
- Pure red cell aplasiaBlood, 2016
- Clinical Validation of a Next-Generation Sequencing Genomic Oncology Panel via Cross-Platform Benchmarking against Established Amplicon Sequencing AssaysThe Journal of Molecular Diagnostics, 2016
- CTLA-4 and PD-1 PathwaysAmerican Journal of Clinical Oncology, 2016
- Pembrolizumab versus Ipilimumab in Advanced MelanomaThe New England Journal of Medicine, 2015
- Autoimmune Targets of Heart and Skeletal Muscles in Myasthenia GravisArchives of Neurology, 2009
- Mechanisms of action of cyclosporineImmunopharmacology, 2000
- The pathology of large granular lymphocyte leukemiaHuman Pathology, 1989