PEMBROLIZUMAB-INDUCED SARCOID-LIKE REACTION

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pembrolizumab is a humanized monoclonal antibody that targets the programmed cell death-1 receptor in T-cells and becoming more widely utilized. Immunologic checkpoint inhibitors have revolutionized cancer treatment but can be associated with systemic toxicities, including pyrexia, chills, infusion reactions, rarely immunologic phenomena such as sarcoid-like reactions [1]. CASE PRESENTATION: We present case of an 81-year-old female history hypertension, hyperlipidemia, urothelial carcinoma renal pelvis metastatic to retroperitoneal lymph nodes. She had undergone right nephrectomy completed adjuvant chemotherapy carboplatin plus gemcitabine. Afterward, oncology team initiated IV 200 mg every three weeks for maintenance therapy. Follow-up imaging done four months after starting immunotherapy showed solid pulmonary nodule lower lobe measuring 3.7 x 2.1 cm. Due concern metastasis, she underwent percutaneous biopsy which revealed non-caseating granulomas. lacked signs sarcoidosis arthritis, rash, visual change, mediastinal adenopathy, detailed workup fungal mycobacterial diseases was negative. Given recent initiation pembrolizumab, medication-induced reaction considered. DISCUSSION: The differential diagnosis granulomatous disease includes non-infectious etiologies or hypersensitivity pneumonitis, infectious diseases, drug-induced reactions. immune inhibitor used malignancy, it acts by blocking PD-1 located on lymphocytes. Some reports discussed concerns pembrolizumab could exacerbate manifest autoimmune [2, ]. Additionally, few described development granulomas (referred reaction), 3-6 other ipilimumab nivolumab [2,3]. primarily T-cell mediated localized process (affecting either lungs, skin, kidneys), unlike sarcoidosis, disease. However, manifests new lymphadenopathy, often required rule out CONCLUSIONS: This highlights importance understanding relationship between therapies their range toxicities. While effective clinicians should aware unexpected consequences flares pre-existing REFERENCE #1: 1. Naidoo J., Page D.B., Li B.T. Toxicities anti-PD-1 anti-PD-L1 antibodies. Ann Oncol. 2015;26:2375–2391. #2: 2. Cotliar J, Querfeld C, Boswell WJ, Raja N, Raz D, Chen R. Pembrolizumab-associated sarcoidosis. JAAD Rep. 2016;2(4):290-293. Published 2016 Jul 27. doi:10.1016/j.jdcr.2016.06.004 #3: 3. Cheshire SC, Board RE, Lewis AR, Gudur LD, Dobson MJ. Pembrolizumab-induced Sarcoid-like Reactions during Treatment Metastatic Melanoma. Radiology. 2018 Nov;289(2):564-567. DISCLOSURES: No relevant relationships Brent Kaufmann, source=Web Response Vishesh Paul, Kelly Roth,