Nivolumab/pembrolizumab Reactions 1680, p260 - 2 Dec 2017 corticosteroids was continued. Eleven days after onset of the symptoms, an NCS-EMG showed only evidence of a previously documented left median neuropathy at the wrist. Therefore, corticosteroid therapy was stopped. Two months Brachial plexus neuropathy and tendinitis: 2 case after discontinuation of her corticosteroids, she developed a reports new, severe, aching type of pain in her left hand, this time with In a case series, a 56-year-old man developed brachial point tenderness of the flexor retinaculum. A repeat MRI and plexus neuropathy during treatment with pembrolizumab and neurological examination findings were consistent with severe 50-year-old woman developed brachial plexus neuropathy and flexor tendinitis, superimposed on her earlier lower-trunk tendinitis during treatment with nivolumab [dosages not brachial plexitis, however, her weakness and sensory loss had stated] resolved compared with the earlier neurological examination. Case 1: The man with metastatic melanoma positive for B- She remained off nivolumab. She underwent flexor Raf proto-oncogene, serine/threonine kinase (BRAF) V600E retinaculum corticosteroid injections and remained stable, mutation had been taking pembrolizumab infusion. After the with no evidence of symptom recurrence. She was able to ninth pembrolizumab infusion, he developed sudden (<8 return to work as a nurse. hours to maximal deficit) weakness of the left hand associated Author comment: "We reviewed 2 patients prospectively, with loss of sensation and neuropathic pain in the medial in our oncology and neurology clinics, who developed hand, forearm and back of hand. Pain was rated 7 of 10 and brachial plexus neuropathy while undergoing [nivolumab and weakness on the Medical Research Council scale included pembrolizumab] therapy for cancer." "In both of our cases, 75% weakness and sensory loss. The left brachioradialis reflex the symptoms were disablingd-i.e, Grade 3 or 4." was reduced and the left triceps reflex was absent. Four days from the onset of symptoms, a nerve conduction study (NCS) Alhammad RM, et al. Brachial Plexus Neuritis Associated With Anti-Programmed showed low-amplitude median compound muscle action Cell Death-1 Antibodies: Report of 2 cases. Mayo Clinic Proceedings: Innovations, Quality and Outcomes 1: 192-197, No. 2, Sep 2017. Available from: URL: http:// potential recorded from the abductor pollicis brevis, with - USA 803283980 unobtainable F waves, and symmetric medial ante-brachial sensory responses. Electromyographic examination (EMG) showed mildly long duration motor unit potentials in left C7-innervated muscles with no elicitable motor unit activation in the left abductor pollicis brevis and first dorsal interosseous muscles. Recruitment of motor units in muscles innervated by the lower trunk was markedly reduced. Three weeks after onset of symptoms, a repeat NCS-EMG with persistent weakness showed fibrillations in lower trunk and posterior cordeinnervated brachial plexus muscles, with new loss of medial ante-brachial sensory responses, consistent with a lower trunk predominant brachial plexopathy. An MRI of the brachial plexus features suggestive of a lower-trunk plexitis. Therefore, pembrolizumab was stopped and he was treated with methylprednisolone. After the first week of corrective treatment, his finger flexion strength improved. However, both the strength of other previously weak muscles and sensory deficits remained unchanged. His left arm and forearm pain rating decreased to 4 of 10. Subsequently, methylprednisolone was replaced with dexamethasone. Approximately 4 weeks after onset of initial symptoms and 3 weeks after replacement of methylprednisolone, acute-onset (<8 hours), medial- aspect, right-hand and fifth-digit sensory loss, and right-hand finger flexor and abductor weakness was noted. Physical examination showed a 4 of 5 weakness measurement of hypo- thenar and interossei muscles in the right hand, with reduced sensation and paraesthesia involving the medial right hand and fifth digit. Therefore, methylprednisolone was resumed due to concern for recurrent neuropathy/brachial plexitis. Ten weeks after onset of symptoms in the right hand, a repeated NCS- EMG showed evidence of a right lower trunk predominant brachial plexopathy with predominant involvement of the medial cord. Later, he showed a clinical stabilization and as a result, his corticosteroids therapy was slowly stopped. He remained stable, with right-hand symptoms unchanged and no further improvement of left-hand weakness. He was unable to work at his job as a mechanic. Case 2: The woman had been taking infusion of nivolumab for metastatic renal cell carcinoma. After her ninth infusion, she experienced sudden-onset (<8 hours), severe, left medial arm, forearm, and axilla pain, rated at its worst as 10 of 10 severity. Her pain was associated with hand burning, prickling paraesthesia, and loss of feeling extending on the medial forearm and arm, with a 4 of 5 weakness in finger flexors, thenar, and interossei musculature. The left triceps reflex was reduced. She was suspected with brachial neuritis with predominant lower-trunk involvement. Nivolumab was stopped and she was treated with methylprednisolone. She showed rapid improvement of weakness, with strength measure returning and resolution of numbness. Her 0114-9954/17/1680-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved Reactions 2 Dec 2017 No. 1680 Reactions Weekly Springer Journals


Reactions Weekly , Volume 1680 (1) – Dec 2, 2017
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Springer International Publishing
Copyright © 2017 by Springer International Publishing AG, part of Springer Nature
Medicine & Public Health; Drug Safety and Pharmacovigilance; Pharmacology/Toxicology
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