Endocrine Hypophysitis
May 18, 2025Neurologic
May 18, 2025Pneumonitis
Symptom Grade 1
- Radiographic changes only
- Ground glass change, non-specific interstitial pneumonia
Management escalation pathway
Consider delay of treatment
- Monitor Symptoms every 2-3 weeks
- When worsening: treat as grade 2 or 3-4
- Monitor Symptoms every 2-3 weeks
- When worsening: treat as grade 2 or 3-4
Assessment and Investigations
- Chest X-Ray
- Regular blood analysis including CRP
- Consider sputum sample and screening for viral, opportunistic or specific bacterial infections (mycoplasma, legionella) depending on the clinical contact
Check in medical history
-Underlying cardiac or respiratory disease: pulmonary hypertension, connective tissue disease (eg preexisting interstitial lung disease)
-Past or ongoing infectious diseases: HIV, Influenza, Mycobacterium Tuberculosis exposure
-Smoking, travel and allergens history (including exposure to home occupational aeroallergens)
Differential Diagnosis
- Other causes of pneumonia (including atypical pneumonia, Pneumocystis Jirovicei, Tuberculosis, …)
- Carcinomatous lymphangitis
- Pulmonary oedema
- Pulmonary emboli
- Sarcoidosis
Steroid weaning upon symptom control
- Grade 2: wean oral steroids over at least 6 weeks, titrate to symptoms
- Grade 3/4: wean steroids over at least 8 weeks, check evolution with CT scan
Caution during steroid treatment:
- Calcium & vitamin D supplementation as per local guidelines
- Pneumocystis prophylaxis to be considered: Cotrimoxazol 480mg 3 times a week
Restart immunotherapy
- Should be discussed multidisciplinary among oncologist and pneumologist patient should be included in risk assessment (only 7 out 10 cases of pneumonitis had a relaps of pneumonitis upon ICPI restart https://www.ncbi.nlm.nih.gov/pubmed/28798088)
- Only indicated once steroids are completely weaned and CT lung is completely cleared
Symptom Grade 2
- Mild/moderate new symptoms
- Dyspnoea, cough, chest pain
Management escalation pathway
Withhold ICPi
- Monitor symptoms: hospitalize patient in case of doubt
- Start antibiotic if suspicion of infection (fever, CRP, neutrophil counts, purulent sputa)
- If no evidence of infection or no improvement with antibiotics after 48h add (methyl)prednisolone 1 mg/kg/day orally
- If no improvement after 48h of oral prednisolone, manage as per Grade 3
- Consider Pneumocystis prophylaxis depending on the clinical context (especially in immunosuppressed and lymphopenic patients)
Assessment and Investigations
- High resolution CT
-Regular blood analysis including CRP
-Analyse sputum sample (incl screening for viral, opportunistic or specific bacterial infections (mycoplasma, legionella))
- Discuss bronchoscopy and BAL with pneumologist
- Perform lung function tests, including TCLO
Check in medical history
- Underlying cardiac or respiratory disease: pulmonary hypertension, connective tissue disease (eg preexisting interstitial lung disease)
-Past or ongoing infectious diseases: HIV, Influenza, Mycobacterium Tuberculosis exposure
-Smoking, travel and allergens history (including exposure to home occupational aeroallergens)
- Discuss previous exposure to thoracic radiotherapy with radiotherapist
Differential Diagnosis
- other causes of pneumonia (including atypical pneumonia, Pneumocystis, Tuberculosis, …)
-Carcinomatous lymphangitis
-Pulmonary oedema
-Pulmonary emboli
-Sarcoidosis
Steroid weaning upon symptom control
- Grade 2: wean oral steroids over at least 6 weeks, titrate to symptoms
- Grade 3/4: wean steroids over at least 8 weeks (evaluate with CT scan)
Caution during steroid treatment:
- Calcium & vitamin D supplementation as per local guidelines
- Pneumocystis prophylaxis to be considered: Cotrimoxazol 480mg 3 times a week
Restart immunotherapy
- Should be discussed multidisciplinary among oncologist and pneumologist patient should be included in risk assessment (only 7 out 10 cases of pneumonitis had a relaps of pneumonitis upon ICPI restart https://www.ncbi.nlm.nih.gov/pubmed/28798088)
- Only indicated once steroids are completely weaned and CT lung is completely cleared
Symptom Grade 3 or 4
- Severe new symptoms
- New or worsening hypoxia
- Life threatening
- Difficulty in breathing, ARDS
Management escalation pathway
Discontinue ICPi
- ospitalize patient, consider ICU care
- Start (methyl)prednisolone i.v. 2 mg/kg/day + cover with empiric antibiotics
- consider treatment with cotrimoxazole for Pneumocystis (until PCR comes out negative)
Assessment and Investigations
- Perform blood test
-Analyze sputum for bacteria, viral and other opportunistic infections
- High resolution CT
- Bronchoscopy and BAL as well as lung function tests to be discussed with pneumologist
If no improvement or worsening after 48h
-Discuss addition of Infliximab 5 mg/kg or other secondary immunosuppressant with pneumologist or in multidisciplinary board
-Continue with i.v. steroids
-Exclude other diagnosis including diaphragm paralysis due to concurrent immune related (cardio)myositis
Check in medical history
- Underlying cardiac or respiratory disease: pulmonary hypertension, connective tissue disease (eg preexisting interstitial lung disease)
- Past or ongoing infectious diseases: HIV, Influenza, Mycobacterium Tuberculosis exposure
- Smoking, travel and allergens history (including exposure to home occupational aeroallergens)
- Discuss previous exposure to thoracic radiotherapy with radiotherapist
Differential Diagnosis
Steroid weaning
-Other causes of pneumonia (including atypical pneumonia, Pneumocystis, Tuberculosis, …)
-Carcinomatous lymphangitis
-Pulmonary oedema
-Pulmonary emboli
-Sarcoidosis
-Other causes of pneumonia (including atypical pneumonia, Pneumocystis, Tuberculosis, …)
-Carcinomatous lymphangitis
-Pulmonary oedema
-Pulmonary emboli
-Sarcoidosis
Steroid considerations
-Grade 2: wean oral steroids over at least 6 weeks, titrate to symptoms
-Grade 3/4: wean steroids over at least 8 weeks (evaluate with CT scan)
Caution during steroid treatment:
-Calcium & vitamin D supplementation as per local guidelines
-Pneumocystis prophylaxis to be considered: Cotrimoxazol 480mg 3 times a week
Restart immunotherapy