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• W4387268743 abstract "SESSION TITLE: Pulmonary Potpourri: Rarest of the Rare SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: With increased use of immune checkpoint inhibitors (ICI) for cancer, immune related adverse events (irAE) are more prevalent. We report an irAE presenting with hypercapnic respiratory insufficiency. CASE PRESENTATION: A 79-year-old man with stage IV RCC presented to the emergency room 3 weeks after his first cycle of nivolumab and ipilimumab with hypercapnic respiratory insufficiency. Venous blood gas revealed: pH 7.18, pCO2 118.5 mmHg. Labs showed elevated troponins, creatinine kinase, and transaminases. Computed tomography of the chest demonstrated bilateral atelectasis without pulmonary infiltrates. There were no ischemic changes on electrocardiogram and a transthoracic echocardiogram was normal. Despite bilevel positive airway pressure (BiPAP) initiation, respiratory acidosis continued even after 10 days. A right and left heart catheterization found a pulmonary capillary wedge pressure of 18 mmHg, cardiac output of 7.69 L/min, cardiac index of 3.49 L/min/m2 by Fick's principle, and clean coronary arteries. An endomyocardial biopsy was negative for inflammatory infiltration. Skeletal muscle electromyogram (EMG) and nerve conduction studies (NCS) resulted with mild myopathy. Subsequent diaphragmatic EMG and NCS had severe myopathy and absent phrenic nerve stimulation. Ultrasound thickness of the diaphragm was 1 mm without increasing for respiratory effort. ICI mediated diaphragmatic neuropathy and myopathy was diagnosed. Treatment included intravenous methylprednisolone, infliximab, abatacept, rituximab, and plasmapheresis. He underwent tracheostomy placement on hospital day 11 due to minimal improvement. He was discharged to a long-term acute care hospital on hospital day 20 on pressure support ventilation with 2-4 hours of trach collar daily. Two months after discharge he required nocturnal ventilatory support and shortly thereafter passed away. DISCUSSION: irAEs affect any organ system resulting in myocarditis, adrenalitis, polymyositis, myopathy, pneumonitis, hepatitis, myasthenia gravis and others. Diaphragmatic dysfunction is an uncommon form of irAE and may be diagnosed by diaphragmatic EMG, NCS, ultrasound study, or biopsy. Treatment includes systemic steroids, plasmapheresis, immunosuppressive medications, respiratory support, and cessation of causative medications. ICI related diaphragmatic dysfunction should be suspected in those patients at risk with hypoxia, hypercapnia, or prolonged invasive or non-invasive ventilation without a distinct etiology. CONCLUSIONS: Recognition of irAEs is paramount. Our case highlights the potential for severe combined diaphragmatic myopathy and phrenic neuropathy with use of dual ICIs. REFERENCE #1: Baldessari C, et al. Myocarditis and diaphragmatic rhabdomyolysis with respiratory failure in a patient with metastatic melanoma treated with Nivolumab. J Oncol Pharm Pract. 2022 Apr;28(3):750-753. doi: 10.1177/10781552211067424. Epub 2021 Dec 29. PMID: 34964671. REFERENCE #2: Srinivasan M, Taylor AM, Long GV, et al. Acute bilateral phrenic nerve neuropathy causing hypercapnic respiratory associated with checkpoint inhibitor immunotherapy. Respir Med Case Rep. 2021 Oct 21;34:101533. doi: 10.1016/j.rmcr.2021.101533. PMID: 34745870; PMCID: PMC8554264. REFERENCE #3: Archibald W, et al. Brief Communication: Immune Checkpoint Inhibitor-induced Diaphragmatic Dysfunction: A Case Series. Journal of Immunotherapy. 2020; 43 (3): 104-106. doi: 10.1097/CJI.0000000000000313. DISCLOSURES: No relevant relationships by Lara Bashoura No relevant relationships by Saadia Faiz No relevant relationships by Jeremy Walder" @default.
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• W4387268743 date "2023-10-01" @default.
• W4387268743 modified "2023-10-03" @default.
• W4387268743 title "HYPERCAPNIC RESPIRATORY INSUFFICIENCY ASSOCIATED WITH DUAL IMMUNE CHECKPOINT INHIBITORS IN A PATIENT WITH RENAL CELL CARCINOMA" @default.
• W4387268743 doi "https://doi.org/10.1016/j.chest.2023.07.3574" @default.
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