Amal Abudouleh, Malak Sondoqah, Areen Said
The development of immune checkpoint inhibitors (ICIs) such as nivolumab, a programmed death receptor-1 (PD-1) inhibitor, has transformed the management of numerous malignancies. However, they are associated with multiple immune-related adverse events (irAEs), including central nervous system (CNS) demyelination such as acute disseminated encephalomyelitis (ADEM). We report a case of ADEM following nivolumab monotherapy and review the literature on similar presentations. We present the case of a patient with Hodgkin lymphoma who presented with confusion, disorientation, and seizures following nivolumab therapy. Serial magnetic resonance imaging (MRI) revealed the development of multifocal white matter lesions suggestive of demyelination. The clinical picture, coupled with extensive investigations, led to a diagnosis of ADEM. The patient was managed with intravenous (IV) methylprednisolone, IV immunoglobulin (IVIG), and plasmapheresis and showed clinical improvement. A review of the literature yielded only a few examples of nivolumab monotherapy-induced autoimmune encephalitis and ADEM. The overlap in the clinical presentations of those neurological adverse events could make the diagnosis more challenging. ICIs are associated with several CNS irAEs, such as ADEM. This case highlights the need for high clinical vigilance for ADEM, an ICI-related CNS complication. Serial imaging and exclusion of alternative etiologies are essential for timely diagnosis and management. Patient outcomes may be improved by early detection and intervention.