Stevens-Johnson Syndrome–Like Reaction After Exposure to Pembrolizumab and Recombinant Zoster Vaccine in a Patient With Metastatic Lung Cancer

Abstract

Stevens-Johnson syndrome (SJS) is a life-threating mucocutaneous reaction predominantly induced by drugs. Targeted cancer therapies such as pembrolizumab, which has been approved for the treatment of metastatic malignancy, can cause severe skin toxicities, including SJS. They are rare and inconsistently reported. In this article, we report the case of a 80-year-old woman with metastatic non–small cell lung cancer who had a SJS-like eruption involving oral mucosa after 15 weeks of exposure of pembrolizumab (6 doses) and 7 days after 1 dose of recombinant zoster vaccine. SJS is a rare blistering disorder with high mortality rate and significant morbidity. Causes include drugs, herpes viruses, and immunization. The timing of the eruption soon after the receipt of recombinant zoster vaccine suggests a role of vaccination in our patient, yet patients receiving cancer immunotherapy may develop late-onset skin toxicity. Therefore, we recommend long-term monitoring for mucocutaneous reactions after initiation of pembrolizumab. Further research is needed to characterize the immunological pathogenesis and improve timely recognition and treatment strategies.

Cemiplimab for Locally Advanced and Metastatic Cutaneous Squamous-Cell Carcinomas: Real-Life Experience from the French CAREPI Study Group

“…One cemiplimab-related death from toxic epidermal necrolysis occurred. About 20 Stevens–Johnson syndrome/toxic epidermal necrolysis cases have been reported with other inhibitors of PD-1 or its ligand [ 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 ]. Toxic epidermal necrolysis is responsible for high mortality [ 56 ].…”

Oral manifestations of immune‐related adverse events in cancer patients treated with immune checkpoint inhibitors

“…Oral lesions do not appear to discriminate based on site and have affected the buccal mucosa, floor of mouth, hard palate, gingiva, and tongue (Hwang et al, 2019;Logan et al, 2020;Riano et al, 2020). A buccal mucosa biopsy revealed nonspecific findings of a focally ulcerated mildly parakeratotic epithelium with a diffuse acute and chronic inflammatory infiltrate in the underlying connective tissue (Riano et al, 2020). Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis -like (particularly TEN-like) reactions are associated with significant morbidity and mortality.…”

“…These reactions have presented 3 days to 7 months following initiation of ICI therapy (Cai et al, 2020;Goldinger et al, 2016;Hwang et al, 2019;Keerty et al, 2020;Maloney et al, 2020;Riano et al, 2020;Saw et al, 2017). In several cases, SJS-like and TEN-like reactions were preceded by prodromal skin rashes that subsequently evolved into mucosal and skin denudation more characteristic of the conditions (Cai et al, 2020;Goldinger et al, 2016;Keerty et al, 2020;Maloney et al, 2020).…”

“…Stevens‐Johnson Syndrome (SJS)‐like and Toxic Epidermal Necrolysis (TEN)‐like reactions have been reported in patients on pembrolizumab and nivolumab, as well as combination treatment with nivolumab and ipilimumab (Keerty et al, 2020; Logan et al, 2020). These reactions have presented 3 days to 7 months following initiation of ICI therapy (Cai et al, 2020; Goldinger et al, 2016; Hwang et al, 2019; Keerty et al, 2020; Maloney et al, 2020; Riano et al, 2020; Saw et al, 2017). In several cases, SJS‐like and TEN‐like reactions were preceded by prodromal skin rashes that subsequently evolved into mucosal and skin denudation more characteristic of the conditions (Cai et al, 2020; Goldinger et al, 2016; Keerty et al, 2020; Maloney et al, 2020).…”

“…In several cases, SJS‐like and TEN‐like reactions were preceded by prodromal skin rashes that subsequently evolved into mucosal and skin denudation more characteristic of the conditions (Cai et al, 2020; Goldinger et al, 2016; Keerty et al, 2020; Maloney et al, 2020). In some cases, the presenting signs and symptoms included painful oral lesions (erosions, ulcers, bullae) and hemorrhagic crusting of the lips (Hwang et al, 2019; Riano et al, 2020; Saw et al, 2017). Oral lesions do not appear to discriminate based on site and have affected the buccal mucosa, floor of mouth, hard palate, gingiva, and tongue (Hwang et al, 2019; Logan et al, 2020; Riano et al, 2020).…”