Isolated Gastritis Secondary to Immune Checkpoint Inhibitors Complicated by Superimposed Cytomegalovirus Infection

Abstract

Immune checkpoint inhibitors such as nivolumab increase the T-cell destruction of malignancies but can also trigger a broad variety of immune-related adverse events (irAEs). Colitis as an irAE is well-documented, but upper gastrointestinal tract involvement is primarily unrecognized. We present a patient who developed gastritis as an irAE after multiple cycles of nivolumab and initially responded well to steroid therapy but then developed superimposed cytomegalovirus infection. The similarity between both presentations highlights the importance of having a broad differential diagnosis in patients with gastrointestinal complaints treated with immune checkpoint inhibitors and the need for further studies to better characterize gastritis as an irAE.

Immune checkpoint inhibitor gastritis is often associated with concomitant enterocolitis, which impacts the clinical course

“…Of these immune-related adverse events (irAEs), enterocolitis is one of the most frequent and severe, causing abdominal pain and/or diarrhea that can be life-threatening. 1,2 There are scarce data about gastrointestinal (GI) irAEs involving the upper GI tract, limited to case reports [3][4][5][6][7][8][9][10][11][12][13][14][15][16] and a few small series. [17][18][19][20][21][22] In earlier retrospective cohorts of 41 and 80 patients with GI-related irAEs, gastritis represented only approximately 5% of all GI luminal irAEs.…”

A Novel Intersection - Cytomegalovirus Gastritis Following Cemiplimab and Talimogene Laherparepvec in a Patient with Advanced Cutaneous Squamous Cell Carcinoma: a Case Report

“…Tay et al [3] noted a mere 0.3% overall occurrence of CMV detection in those administered ICIs. In a vast majority of cases, invasive CMV disease in patients with solid malignancies on ICIs complicated irAEs that required high-dose corticosteroids and other immunomodulatory drugs [3,[10][11][12][13][14][15][16][17][18][19][20], which could be explained by the fact that CMV has tropism to in amed tissues. Consequently, there's a signi cant occurrence of CMV infection among patients with severe acute in ammatory bowel disease (IBD), and the frequency is even higher in those with steroid-resistant conditions.…”

“…Furthermore, there was no concurrent H. pylori infection or a history of current immunosuppression, as reported in the literature. [3,4,[10][11][12][13][14][15][16][17][18][19][20]22] However, our patient complained of dyspepsia for 6 months halfway through his cemiplimab therapy course, which may have represented an unrecognized form of irAE-gastritis before he was diagnosed with CMV.…”

Immune-Related Uncommon Adverse Events in Patients with Cancer Treated with Immunotherapy

“…In patients receiving immunosuppressive drugs for ICI-related gastritis, symptoms recurrence or exacerbation have been described due to reactivation of opportunistic pathogens such as CMV, Pneumocystis jiroveci , EBV, or even Strongyloides stercoralis hyperinfestation [ 189 , 190 ] with life-threatening complications [ 191 ]. The highest clinical suspicion is warranted in such cases due to the serious clinical implications and the potential misdiagnosis as gastritis-related symptom exacerbation.…”