SHM Converge Scientific Abstract ePoster Gallery-Premature Pembrolizumab Pulmonary Problems: A Case of Atypical Early-Onset Check-Point Inhibitor Pneumonitis

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This case report describes an atypical, very early onset of pembrolizumab-related checkpoint inhibitor pneumonitis (CIP) in a 65-year-old woman with stage III squamous cell non-small cell lung cancer. She had multiple comorbidities, including COPD, rheumatoid arthritis, atrial fibrillation, and a heavy smoking history, and was receiving pembrolizumab after six months of carboplatin/taxol chemotherapy.<br /><br />After only two pembrolizumab infusions over about 30 days, she presented with fever, fatigue, cough, worsening dyspnea, and increased oxygen needs. Initial evaluation showed hypotension, wheezing/rhonchi, anemia, thrombocytopenia, and elevated BNP. Infectious workup was negative, and CT angiography showed no pulmonary embolism or new cancer progression. Despite empiric antibiotics, bronchodilators, and diuresis, her respiratory status worsened.<br /><br />Pulmonology suspected CIP and began corticosteroids, escalating from prednisone 60 mg daily to 1 mg/kg/day, then to 2 mg/kg/day after repeat CT imaging on hospital day 9 revealed new ground-glass opacities throughout the right lung. Because of persistent hypoxemia and poor response to steroids alone, IVIG was added. Within three days of high-dose steroids plus IVIG, her dyspnea improved and oxygen requirements returned to baseline.<br /><br />The patient was discharged to a skilled nursing facility on a prolonged prednisone taper, with oncology follow-up to consider future treatment without pembrolizumab.<br /><br />The key teaching point is that CIP, though rare, can occur much earlier than traditionally expected—potentially after only two pembrolizumab infusions or within four weeks of starting therapy. Clinicians should consider CIP in any patient on immune checkpoint inhibitors who develops acute respiratory decline, and early treatment with high-dose steroids, with IVIG for refractory cases, may be necessary.

Asset Subtitle

Vidya N. Mullangi

Meta Tag

Author List Vidya N. Mullangi, Vignesh Doraiswamy

Category Clinical Vignettes

Concept Pneumonitis

Concept Pembrolizumab

Concept Glucocorticoid Therapy

Concept Pembrolizumab Discontinuation

Concept Immune-Related Adverse Event

Distinguished Non-Finalist

Presenter Organization The Ohio State College of Medicine

Presenting Author Vidya N. Mullangi

Track Adult

Keywords

pembrolizumab

checkpoint inhibitor pneumonitis

CIP

non-small cell lung cancer

ground-glass opacities

corticosteroids

IVIG

immune checkpoint inhibitor

early onset pneumonitis

respiratory failure

Pneumonitis

Pembrolizumab

Glucocorticoid Therapy

Pembrolizumab Discontinuation

Immune-Related Adverse Event