背景:细胞因子释放综合征(CRS)是一种以发热和多器官功能衰竭为特征的急性全身性炎症综合征,这是由免疫疗法或某些感染引发的。免疫检查点抑制剂很少引起免疫相关的不良事件-细胞因子释放综合征(irAE-CRS)。本文介绍了2019年冠状病毒病(COVID-19)引发的irAE-CRS病例报告。
方法:一名患有2型糖尿病的60岁男性患者接受了纳武单抗治疗食管胃结合部癌,并出现了两种免疫相关的不良事件:甲状腺功能减退和皮肤病。在他去我们医院的11天前,他发烧,被诊断为COVID-19。在他访问前五天,他又发烧了,随着一般的不适,水溶性腹泻,和四肢肌痛.一入场,病人处于多器官衰竭状态,虽然感染源未知,初步诊断为感染性休克。尽管使用抗菌药物进行全身管理,但患者的病情不稳定,大剂量血管加压药,和静脉输液。根据他使用nivolumab的历史,我们怀疑由于irAE(irAE-CRS)引起的CRS。开始类固醇脉冲治疗(甲基强的松龙1克/天),病人暂时康复了。然而,他的呼吸状况恶化;因此,他被放置在呼吸机上,托珠单抗被添加到治疗中。他的肌肉力量恢复到可以在家生活的程度,随后出院。
结论:在以前接受过免疫检查点抑制剂治疗的患者中,当除炎症发现外还观察到多器官损伤时,应将irAE-CRS视为鉴别诊断。建议开始用类固醇治疗;如果疾病难治,其他免疫抑制疗法如托珠单抗应尽早引入.
BACKGROUND: Cytokine release syndrome (CRS) is an acute systemic inflammatory syndrome characterized by fever and multiple organ failure, which is triggered by immunotherapy or certain infections. Immune checkpoint inhibitors rarely cause immune-related adverse event- cytokine release syndrome (irAE-CRS). This article presents a case report of irAE-CRS triggered by coronavirus disease 2019 (COVID-19).
METHODS: A 60-year-old man with type 2 diabetes received nivolumab treatment for esophagogastric junction carcinoma and experienced two immune-related adverse events: hypothyroidism and skin disorder. Eleven days before his visit to our hospital, he had a fever and was diagnosed with COVID-19. Five days before his visit, he developed a fever again, along with general malaise, water soluble diarrhea, and myalgia of the extremities. On admission, the patient was in a state of multiple organ failure, and although the source of infection was unknown, a tentative diagnosis of septic shock was made. The patient\'s condition was unstable despite systemic management with antimicrobial agents, high-dose vasopressors, and intravenous fluids. We suspected CRS due to irAE (irAE-CRS) based on his history of nivolumab use. Steroid pulse therapy (methylprednisolone 1 g/day) was started, and the patient temporarily recovered. However, his respiratory condition worsened; consequently, he was placed on a ventilator and tocilizumab was added to the treatment. His muscle strength recovered to the point where he could live at home, and was subsequently discharged.
CONCLUSIONS: In patients previously treated with immune checkpoint inhibitors, irAE-CRS should be considered as a differential diagnosis when multiple organ damage is observed in addition to inflammatory findings. It is recommended to start treatment with steroids; if the disease is refractory, other immunosuppressive therapies such as tocilizumab should be introduced as early as possible.