Atezolizumab-induced anaphylactic shock in a patient with hepatocellular carcinoma undergoing immunotherapy: A case report

Abstract

BACKGROUND Atezolizumab is a programmed death ligand 1 (PD-L1) inhibitor, and its combination with bevacizumab has been proven an effective immunotherapy for unresectable hepatocellular carcinoma (HCC). Treatment with immune checkpoint inhibitors (ICIs) can lead to hypersensitivity reactions; however, anaphylactic shock is rare. We present a case of life-threatening anaphylactic shock during atezolizumab infusion and performed a relevant literature review. CASE SUMMARY A 75-year-old man was diagnosed with HCC recurrence after hepatectomy. He was administered immunotherapy with atezolizumab plus bevacizumab after an allergy to a programmed death-1 (PD-1) inhibitor. The patient showed a sudden onset of dizziness, numbness, and lack of consciousness with severe hypotension during atezolizumab infusion. The treatment was stopped immediately. The patient’s symptoms resolved after 5 mg dexamethasone was administered. Because of repeated hypersensitivity reactions to ICIs, treatment was changed to oral targeted regorafenib therapy. CONCLUSION Further research is necessary for elucidating the hypersensitivity mechanisms and establishing standardized skin test and desensitization protocols associated with PD-1 and PD-L1 to ensure effective treatment with ICIs.

Symptom clusters and their predictors in patients with lung cancer and treated with programmed cell death protein 1 immunotherapy

“… 33 The etiology of this cluster is not entirely clear, but it may be related to inflammation changes and damage to peripheral neurons caused by chemotherapy drugs. 34 Furthermore, chemotherapy is not the only cause for these symptoms –– palliative radiation therapy, 35 surgery, 36 and even PD-1 immunotherapy 23 , 37 have also been found to be related to pain and numbness. The mechanisms leading to this symptom cluster need further exploration.…”

Case report: Pembrolizumab as an alternative to atezolizumab following a severe infusion reaction

“…Severe infusion reactions with atezolizumab are rare, but a few related cases have been reported ( 6 , 14 ). Although successful desensitization with atezolizumab has been reported ( 6 ), re-administration after severe infusion reactions should be carefully considered.…”

“…Although the burden of side effects related to cytotoxic drugs has been alleviated with the introduction of ICIs, cases of severe infusion reactions due to ICIs are still reported occasionally ( 14 , 17 , 18 ). Understanding the mechanisms underlying these infusion reactions is critical to effectively manage and mitigate associated risks, but elucidating the hidden pathways of immune responses remains a considerable challenge for physicians.…”

Complications of immunotherapy in advanced hepatocellular carcinoma

“…He improved but did not resume atezolizumab/bevacizumab therapy. 25 An 82-year-old man presented to the emergency department with dyspnea 3 days after receiving atezolizumab/bevacizumab. Despite receiving treatment with steroids and undergoing low tidal mechanical ventilation with high positive end-expiratory pressure, he was diagnosed with acute respiratory distress syndrome and unfortunately succumbed 31 hours later.…”