Khyber Medical University Journal (Jun 2024)
Eosinophilic fasciitis as an immune-related adverse event of Pembrolizumab in Hodgkin’s lymphoma: a case report
Abstract
BACKGROUND: Immune checkpoint inhibitors have transformed the treatment landscape for several types of cancer. These agents boost the patient's immune system by targeting cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), programmed cell death protein 1 (PD-1), and its ligand. However, the enhanced immune activity can lead to a range of immune-related adverse events (irAEs), including rheumatological manifestations. CASE PRESENTATION: We report a case of an 82-year-old male diagnosed with eosinophilic fasciitis. He had been receiving maintenance pembrolizumab at 200 mg every three weeks for the past three years for Hodgkin lymphoma. He presented with pain in his thumbs and wrists, accompanied by skin thickening and induration of his forearms and lower limbs. Additionally, he reported myalgia, arthralgia, fatigue, and difficulty with manual dexterity. Blood tests revealed a normal full blood count, with no lymphopenia or eosinophilia. A connective tissue disease screen was negative, including tests for anti-centromere antibodies and anti-SCL 70. An MRI of the whole body showed fasciitis, predominantly in the thighs. A full-thickness skin biopsy revealed moderate infiltration by mononuclear lymphocytes and plasma cells. Pembrolizumab was discontinued, and the patient was started on 30 mg prednisolone with a gradual taper over three months. Additionally, methotrexate 20 mg once weekly was added to his regimen. Subsequently, the skin thickening and induration in his forearms and lower limbs improved. CONCLUSION: This case highlights eosinophilic fasciitis as a potential immune-related adverse event associated with pembrolizumab. Discontinuation of pembrolizumab and initiation of corticosteroids and methotrexate significantly improved the patient's symptoms and skin condition.
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