Case Report: ICIs-induced Guillain–Barré syndrome recovered from mycophenolate mofetil

Abstract

The emergence of immune checkpoint inhibitors (ICIs) has significantly prolonged the survival time of cancer patients. However, it may also lead to various immune-related adverse events (irAEs), including Guillain–Barré syndrome (GBS), a rare type of irAE. Most GBS patients can recover spontaneously due to the self-limited nature of the disease, but severe cases can result in respiratory failure or even death. Here we report a rare case of GBS occurring in a 58-year-old male patient with non-small cell lung cancer (NSCLC) who developed muscle weakness and numbness of the extremities during chemotherapy combined with KN046, a PD-L1/CTLA-4 bispecific antibody. Despite receiving methylprednisolone and γ-globulin, the patient’s symptoms did not improve. However, there was significant improvement after treatment with mycophenolate mofetil (MM) capsules, which is not a routine regimen for GBS. To the best of our knowledge, this is the first reported case of ICIs-induced GBS that responded well to mycophenolate mofetil instead of methylprednisolone or γ-globulin. Thus, it provides a new treatment option for patients with ICIs-induced GBS.

Case report: Resolution of Guillain-Barré syndrome in a patient with dual primary tumors after treatment with rituximab

“…Both types of drugs have the potential to induce GBS ( 9 ). In similar instances, the patients of Ding et al ( 10 ) and Manam et al ( 11 ) were also treated with a combination of chemotherapy and ICIs. Both authors considered GBS as a possible result of ICIs.…”

“…Apart from GBS, antineoplastic chemotherapeutic agents can directly induce neurotoxicity and lead to chemotherapy-induced peripheral neuropathy (CIPN). It has been demonstrated that immune checkpoint inhibitors are associated with a higher risk of neurological adverse events compared to control groups, yet this risk is significantly lower when compared to chemotherapeutic agents ( 10 , 12 ). Both conditions have comparable clinical symptoms, which may lead to weakness and numbness in the limbs, as well as sensory abnormalities.…”

“…Due to the unclear pathogenesis of GBS and the intricate clinical symptoms, there currently exists no proven and efficient treatment for GBS. According to the 2021 CSCO guidelines for ICIs-related toxicity, both methylprednisolone and IVIG are established therapies for GBS ( 10 ). ICI-induced GBS is believed to be mainly linked to T-cell activation ( 13 ).…”

“…This combination therapy seems to more effectively target the underlying immunological mechanisms involved ( 3 , 15 ). Furthermore, in cases of refractory Guillain-Barré syndrome, where conventional treatment regimens may not produce the desired outcomes, alternative immunosuppressants such as TNFα inhibitors, mescaline or anti-thymocyte globulin, and monoclonal antibodies like rituximab, represent viable therapeutic options ( 7 , 8 , 10 ).…”

Immune Checkpoint Inhibitor-Induced Guillain Barre Syndrome: A Single-Institution Case Report and Narrative Review

“…Plasma exchange (PE) can be used as a second-line treatment if previous treatments are ineffective. However, the efficacy of plasmapheresis as a first-line treatment is unknown [ 29 ]. One case report in the literature reports improvement in ICIs-induced GBS with the use of mycophenolate mofetil [ 29 ].…”