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Abstract

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Article in Japanese

Case Report

Pembrolizumab-induced, possibly trimethoprim-sulfamethoxazole-related hepatitis requiring treatment with high dose prednisolone and mycophenolate mofetil

Fuminori Tomyoa  Konomi Kobayashia  Koji Saitob  Atsushi Tanakac  Masao Yamaguchia  Hiroyuki Nagasea 

aDivision of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine
bDepartment of Pathology, Teikyo University Hospital
cDivision of Gastroenterology, Department of Medicine, Teikyo University School of Medicine

ABSTRACT

A 66-year-old man was diagnosed with driver mutation in wild-type lung adenocarcinoma (clinical stage IVB, T4N3M1c BRA, OTH) with a tumor proportion score for programmed death ligand 1 expression of 70%–80%. After receiving radiation therapy for brain metastasis with oral steroids and trimethoprim-sulfamethoxazole (TMP-SMX), the patient received pembrolizumab as first-line treatment. Soon after, the patient developed hepatitis that did not improve after TMP-SMX withdrawal. On diagnosis of pembrolizumab-induced hepatitis, the patient was treated with 50mg/day prednisolone for two weeks and transaminase levels returned to normal. Prednisolone was decreased to 40mg/day and TMP-SMX was restarted. A few hours later, the patient developed fever and re-elevation of transaminases. By increasing prednisolone to 100mg/day and adding mycophenolate mofetil, his hepatitis gradually improved; however, the patient died on day 98 because of the progression of lung cancer. An autopsy revealed drug-induced hepatocellular injury. Severe pembrolizumab-induced hepatitis is rare. In this patient, under unrestrained T cell activation with pembrolizumab, an allergic reaction to TMP-SMX which involves T cells, may have worsened the hepatitis.

KEYWORDS

Pembrolizumab  Immune-related adverse event (irAE)  Hepatitis  Trimethoprim-sulfamethoxazole  Mycophenolate mofetil 

Received 18 Jul 2019 / Accepted 13 Nov 2019

AJRS, 9(2): 99-103, 2020

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