Diffuse alveolar hemorrhage with nivolumab monotherapy

Area of Science:

• Pulmonology
• Oncology
• Immunology

Background:

• Immunotherapy, particularly immune checkpoint inhibitors like nivolumab, has revolutionized cancer treatment.
• However, these therapies can induce immune-related adverse events, including pneumonitis.

Observation:

• A 60-year-old man developed respiratory insufficiency following two cycles of nivolumab monotherapy.
• Radiographic findings showed progression from subtle ground-glass infiltrates to diffuse opacities and consolidation.
• Bronchoscopy revealed negative cultures but progressive bloody lavage fluid, indicative of diffuse alveolar hemorrhage.

Findings:

• The patient's condition was refractory to high-dose corticosteroids, empiric antimicrobial therapy, and infliximab.
• Autopsy confirmed extensive alveolar hemorrhage as the cause of death.
• This case underscores the potential for severe pulmonary toxicity with nivolumab.

Implications:

• Immunotherapy-induced pneumonitis can present with diffuse alveolar hemorrhage, a critical and potentially fatal complication.
• Early recognition and diagnosis are crucial for managing these adverse events.
• This case highlights the need for vigilance regarding pulmonary toxicity in patients receiving nivolumab.