Pneumonitis – Grade 1
Management escalation pathway
Consider delay of treatment
- 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
Abbrevations
ICPi: Immune Checkpoint Blockade Inhibition
ARDS: Acute Respiratory Distress Syndrome
CRP: C Reactive Protein
ULN: Upper Limit of Normal
TFT: Thyroid Function Test
TCLO: Transfer Factor for Carbon Monoxide
MMF: Mycophenolate mofetil
