Immunoglobulin G4 associated autoimmune cholangitis and pancreatitis following the administration of nivolumab: A case report

Abstract

BACKGROUND Immune checkpoint inhibitors have significantly improved survivals for an increasing range of malignancies but at the cost of several immune-related adverse events, the management of which can be challenging due to its mimicry of other autoimmune related disorders such as immunoglobulin G4 (IgG4) related disease when the pancreaticobiliary system is affected. Nivolumab, an IgG4 monoclonal antibody, has been associated with cholangitis and pancreatitis, however its association with IgG4 related disease has not been reported to date. CASE SUMMARY We present a case of immune-related pancreatitis and cholangiopathy in a patient who completed treatment with nivolumab for anal squamous cell carcinoma. Patients IgG4 levels was normal on presentation. She responded to steroids but due to concerns for malignant biliary stricture, she opted for surgery, the pathology of which suggested IgG4 related disease. CONCLUSION We hypothesize this case of IgG4 related cholangitis and pancreatitis was likely triggered by nivolumab.

Immune Checkpoint Inhibitor-related Pancreatitis: A Case Series, Review of the Literature and an Expert Opinion

“…Although ICI-related pancreatitis shows similarities with autoimmune pancreatitis, in case reports, IgG4 is reported within the normal range 5 . There are case reports in which patients develop histological proven IgG4-related pancreatitis 6 and cholangitis after nivolumab 6,7 . However in our three cases IgG4 was normal, confirming the data in the literature on usually normal serum IgG4 levels in ICI-related pancreatitis.…”

Clinical pattern of checkpoint inhibitor-induced liver injury in a multicentre cohort

“…Recently, a few cases of IgG-4-related disease related to pancreatitis, pleural involvement, and cholangitis have been reported. [28] , [29] , [30] In our patient cohort, only one patient with severe interstitial pneumonia and refractory cholangitis had histological features fulfilling the criteria of IgG-4-related disease. We thus decided to treat this patient with rituximab, and the outcome was complete resolution of both aforementioned irAEs.…”

Immune Checkpoint Inhibitor-induced Pancreatitis with Pancreatic Enlargement Mimicking Autoimmune Pancreatitis: A Case Report and Review of the Literature

“…Twelve patients with ICI-induced pancreatitis underwent an evaluation of histologic specimens for the presence of metastases, obtained by surgical treatment, autopsy, and a biopsy. Although the imaging findings of patients with ICI-induced pancreatitis resembled those with AIP, there was only one patient with infiltration by IgG4-positive plasma cells ( 35 ). Five patients had predominantly neutrophilic infiltrates, five had predominantly lymphocytic infiltrates, and two had both types of infiltrates.…”