Nidhi Kuchimanchi, Sai Gajula, Elizabeth M. Gaughan, Russell G. Witt
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Immune Checkpoint Inhibitor-Related Dysautonomia in Merkel Cell Carcinoma: A Case Report
Background
Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that block inhibitory pathways that cancer cells exploit to suppress T-cell activation. Although immune-related adverse events (irAEs) linked to ICI therapy are well documented and encompass dermatologic, endocrine, gastrointestinal, hepatic, and neurologic systems, ICI-related dysautonomia remains a rare phenomenon. Management of ICI-related dysautonomia is undefined.
Case
We report the case of a 57-year-old male patient treated with neoadjuvant nivolumab for Merkel cell carcinoma who developed ICI-related dysautonomia. His dysautonomia was characterized by orthostatic hypotension, urinary retention, hearing loss, and binocular diplopia in addition to the development of ICI-related hepatitis. We describe the patient's course, including the treatment and outcome of his dysautonomia, and review the literature on this rare toxicity.
Conclusion
Due to the mechanism of action of ICIs, irAEs can present with a wide range of manifestations. In this case, prompt recognition of ICI-induced dysautonomia and timely administration of intravenous immunoglobulin (IVIG) led to significant clinical improvement. ICI-induced dysautonomia is a rare condition that is difficult to diagnose and manage.
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