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Correspondence to Professor Dan Xu; [email protected]
Background
Durvalumab is an immune checkpoint inhibitor (ICI), which is approved in Australia for the treatment of uroepithelial carcinoma and stage III non-small-cell lung cancer (NSCLC) without progression following platinum-based chemoradiation therapy. It is a human engineered IgG1 monoclonal antibody inhibiting the PD1-ligand binding to the PD-1 receptor. It only binds to the PD1 ligand and not the PD-2 ligand reducing the risk of immune related toxicity.1 It has a reduced side effect profile when compared with the PD receptor inhibitors. The most common serious side effect is pneumonitis (12.6%) which can be fatal. Other side effects include fatigue, diarrhoea, pruritus rash, colitis and endocrinopathies.2 Outcomes of trials with durvalumab have shown a significant improvement in progression free survival compare to placebo of 16.8 months vs 5.6 months and an increased median time of death or distant metastases of 23.2 months vs 14.6 months with placebo.3 We report a case of vasculitis in an 84-year-old woman receiving durvalumab therapy for NSCLC to share the knowledge with our colleagues due to unusual presentation.
Case presentation
An 80-year-old woman was referred for admission by her general practitioner with a 3-day history of painless blue left great toe. There had been no preceding trauma or cold exposure. ‘She had noted the new onset of symptoms of painful Raynaud syndrome in her left hand’. Fourteen months prior, she was diagnosed with stage IIIa (T1N2M0) NSCLC of the right upper lobe on a CT arranged to investigate exertional dyspnoea. Medical history includes ex-smoker of 90 pack-years, ischaemic heart disease, hypertension, dyslipidaemia, aortic stenosis, deep venous thrombosis, chronic back pain with previous L3/4 laminectomy and right hip osteoarthritis.
Her long-term medications include amitriptyline 10 mg daily, aspirin 100 mg daily, frusemide 20 mg daily, methadone 5 mg daily, nifedipine 10 mg daily pregabalin 75 mg mane and 150 mg nocte, valsartan 40 mg.
She completed chemotherapy (carboplatin and paclitaxel) and radiotherapy (50 Gy over 30 sessions), followed by 21 cycles of fortnightly intravenous durvalumab for maintenance treatment. The final dose of durvalumab had been given 6 weeks prior to presentation. During the second month of durvalumab, she had an exacerbation of her chronic back, hip and leg pain. In the fifth...