An Adverse Double-Hit by Pembrolizumab: A Case Report of Bullous Pemphigoid and Pneumonitis
Bibliographic record
Abstract
Immune checkpoint inhibitors like pembrolizumab represent a modern approach to the management of various malignancies, including non-small cell lung cancer. The therapeutic activity of immunotherapy is exerted by the activation of immune cells against the tumor cells. However, systemic activation of the immune system can lead to the development of autoimmune complications known as immune-related adverse events. A combination of rare immune-related adverse events is occasionally observed simultaneously in the same patient. We present the case of a 66-year-old male with squamous non-small cell lung carcinoma who presented to the emergency department with dyspnea and respiratory failure. Imaging findings were consistent with pulmonary embolism and nonspecific interstitial pneumonitis. One month before this event, he was diagnosed with bullous pemphigoid following 21 cycles of treatment with pembrolizumab. The radiological findings, the lack of response to antibiotics, the negative microbiological workup, and the excellent response to corticosteroids established the diagnosis of pembrolizumab-induced pneumonitis. The combination of bullous pemphigoid and pneumonitis secondary to pembrolizumab is rare; only a few case reports exist in the literature. Hence, this case highlights the possibility of multiple immune-related adverse events in the same patient. The exclusion of infectious diseases and other immunologic disorders with a similar clinical presentation is necessary to make the final diagnosis of immune-related adverse events and start the appropriate treatment. Serology, histopathology, and direct immunofluorescence aid to the diagnosis of immune-related bullous pemphigoid; the differential diagnosis includes other pemphigoid or lichenoid diseases, Stevens-Johnson syndrome/toxic epidermal necrolysis, and drug reaction with eosinophilia and systemic symptoms. Imaging, microbiological testing, and bronchoscopy (if possible) confirm the diagnosis of immune-related pneumonitis, which should be differentiated from acute coronary syndrome, cardiogenic pulmonary edema, pulmonary embolism, tumor progression, and lower respiratory tract infections (especially Pneumocystis jirovecii pneumonia in immunocompromised patients). An interdisciplinary approach is necessary for the management of these cases.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.004 |
| Meta-epidemiology (narrow) | 0.003 | 0.003 |
| Meta-epidemiology (broad) | 0.003 | 0.003 |
| Bibliometrics | 0.004 | 0.003 |
| Science and technology studies | 0.004 | 0.002 |
| Scholarly communication | 0.003 | 0.005 |
| Open science | 0.002 | 0.003 |
| Research integrity | 0.011 | 0.006 |
| Insufficient payload (model declined to judge) | 0.003 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".