Central and peripheral demyelinating polyneuropathy during Nivolumab treatment in patient with advanced non-small cell lung cancer (NSCLC): A case report

Immunotherapy with monoclonal antibodies targeting programmed death 1 (PD-1) or programmed death-ligand 1 (PD-L1) such as Nivolumab, Pembrolizumab (antiPD-1) and Atezolizumab (antiPDL-1), has substantially changed the management of advanced non-small cell lung cancer (NSCLC). These agents in 10% of the case may cause immune-related adverse events (irAEs) G3-4 grade such as colitis, rash, thyroiditis, hypophysitis, hepatitis, pneumonia, nephritis. Moreover, few data exist about neurologic immune-related adverse events (neuro irAEs), with potentially life-threatening events derived from clinical trials, single case reports, or small case series, characterized by really aspecific and confounding symptoms, at the onset. As the use of these agents increases, it is important to recognize neuro irAEs early, because they may be serious and potentially fatal and require immediate immunosuppressive therapy. We present a case of a patient with advanced NSCLC who was treated with Nivolumab therapy as second-line treatment. After 12 infusions, he developed severe weakness involving all limbs, respiratory compromise due to central and peripheral nervous system involvement. Nivolumab was discontinued but, despite immunosuppressive therapy, the clinical course worsened, and the patient died 5 months later. This case report is aimed to underline the consciousness of the exsistence of rare neurologic complications derived from the use of immune-checkpoint inhibitors. In the future a multidisciplinary approach is required, to improve and optimize the effect of this essential and powerful therapy.