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    Area of Science:

    • Oncology
    • Rheumatology
    • Immunology

    Background:

    • Immune checkpoint inhibitors (ICIs) are vital in treating advanced cancers but can induce immune-related adverse effects.
    • Inflammatory arthritis is a known adverse effect of ICIs, with severe cases being rare and poorly defined.
    • Distinguishing severe ICI-induced inflammatory arthritis (ICI-IA) from other conditions like septic arthritis is challenging.

    Purpose of the Study:

    • To describe the clinical features of severe ICI-IA.
    • To review the literature on severe ICI-IA and compare it with septic arthritis.
    • To highlight diagnostic challenges and potential management strategies for ICI-IA.

    Main Methods:

    • Case report of a patient with metastatic urothelial carcinoma treated with ICI who developed severe polyarticular inflammatory arthritis.
    • Arthrocentesis of native and prosthetic joints to analyze synovial fluid.
    • Comprehensive literature review of published cases of severe ICI-IA.

    Main Results:

    • The patient's synovial fluid showed elevated white blood cell (WBC) count with neutrophil predominance, mimicking septic arthritis.
    • Infectious workup was negative, leading to a diagnosis of ICI-IA.
    • Literature review revealed similar cases with polyarticular presentation, elevated inflammatory markers, and absence of other rheumatic diseases.

    Conclusions:

    • Severe ICI-IA can present with overlapping features of septic arthritis, causing diagnostic uncertainty.
    • Synovial fluid findings of elevated WBC with neutrophil predominance do not exclude ICI-IA.
    • Early consideration of steroid treatment is recommended for suspected ICI-IA.