Abstract Details

Title Bilateral Sequential Brachial Plexus Neuritis Following Immune Checkpoint Inhibitor Combination Treatment

Topic Neuromuscular and Clinical Neurophysiology (EMG)

Presentation(s) P13 - Poster Session 13 (8:00 AM-9:00 AM)

Poster/Presentation
Number 10-003

Background

Neurologic immune related adverse events associated with ICI are rare; rapid diagnosis and treatment can limit morbidity. Combined ICI treatment is associated with more severe and rapid neurotoxicity. Only 4 BPN cases have been reported. Three were unilateral, predominantly involving the lower trunk (C8-T1) and highly steroid responsive. One affected the anterior interosseous and lateral antebrachial cutaneous nerves.

Objective

To report a rare, debilitating neurotoxicity to combination immunotherapy.

Design/Methods

A 76-year-old woman with lung adenocarcinoma received 3 doses of Nivolumab and one dose of Ipilimumab. She developed numbness and pain, followed by worsening bilateral asymmetric arm weakness 3 weeks after receiving her last Nivolumab dose. Her weakness was diffuse, worse on the right, associated with loss of reflexes. It started on the right arm and involved left arm a week after.

Results EMG confirmed bilateral brachial plexopathy, predominantly affecting roots derived from C6-C7 on right and C5-C6 on left. CSF showed WBC 7, elevated protein 58 g/dL, no malignant cells, normal IgG index and infectious studies. MRI cervical spine and brachial plexus were unremarkable. She received IV methylprednisolone 1 mg/kg for 5 days, IV immunoglobulin total of 2 grams/kg with rapid improvement in her strength and pain.

Conclusions

This may be the first report of bilateral sequential BPN with predominantly upper-mid trunk involvement after dual treatment with Nivolumab and Ipilimumab. Rapid workup, exclusion of confounding factors, and treatment with steroids and immunomodulating agents can lead to significant recovery of function from a debilitating process.

Authors/Disclosures
Osman Ozel, MD (Houston Methodist Hospital) PRESENTER	Dr. Ozel has nothing to disclose.
Merry Chen, MD (MD Anderson Cancer Center)	Dr. Chen has nothing to disclose.
Karin Woodman, MD (M. D. Anderson Cancer Center)	Dr. Woodman has nothing to disclose.