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Immune Checkpoint Inhibitor-Related Dysautonomia in Merkel Cell Carcinoma: A Case Report
Nidhi Kuchimanchi1, Sai Gajula1, Elizabeth M Gaughan1
1School of Medicine, University of Virginia, Charlottesville, Virginia, USA.
Background:
Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that block inhibitory pathways that cancer cells exploit to suppress T-cell activation. Although immune-related adverse events (irAEs) linked to ICI therapy are well documented and encompass dermatologic, endocrine, gastrointestinal, hepatic, and neurologic systems, ICI-related dysautonomia remains a rare phenomenon. Management of ICI-related dysautonomia is undefined.
Case:
We report the case of a 57-year-old male patient treated with neoadjuvant nivolumab for Merkel cell carcinoma who developed ICI-related dysautonomia. His dysautonomia was characterized by orthostatic hypotension, urinary retention, hearing loss, and binocular diplopia in addition to the development of ICI-related hepatitis. We describe the patient's course, including the treatment and outcome of his dysautonomia, and review the literature on this rare toxicity.
Conclusion:
Due to the mechanism of action of ICIs, irAEs can present with a wide range of manifestations. In this case, prompt recognition of ICI-induced dysautonomia and timely administration of intravenous immunoglobulin (IVIG) led to significant clinical improvement. ICI-induced dysautonomia is a rare condition that is difficult to diagnose and manage.
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