Nivolumab-Induced Toxic Epidermal Necrolysis: Rare but Fatal Complication of Immune Checkpoint Inhibitor Therapy

Toxic epidermal necrolysis (TEN) is a rare, but potentially fatal dermatological emergency most commonly caused by medication exposure. It is characterized by skin desquamation affecting over 30% of the body, and it remains a fatal condition with a high mortality rate. Nivolumab, an immune checkpoint inhibitor used in the treatment of various types of malignancies, has been linked to TEN. Nivolumab-induced TEN is a rare phenomenon with a low incidence rate in patients treated with a single-agent immune checkpoint inhibitor, but it has a high mortality rate that exceeds non-nivolumab-induced TEN. Nivolumab-induced TEN can present with many potential complications such as hemodynamic instability from excessive fluid loss, sepsis from bacterial superinfection, and disseminated intravascular coagulation. Due to its high mortality rate, prompt recognition of the condition, immediate withdrawal of the offending drug(s), vigorous skin care, multispecialty collaboration, and close monitoring of complications is needed. We present a case of nivolumab-induced TEN in an elderly male with a history of hepatocellular carcinoma who presented with acute-onset skin desquamation after nivolumab initiation.