Multifocal Pneumonia During a Pandemic

Intro: In patients with advanced melanoma, immune checkpoint inhibitors (ICPIs) have demonstrated a substantial advantage when compared to cytotoxic chemotherapies. By augmenting the immune response with these medications, immune-related adverse effects can occur, and often include dermatological toxicity, hepatotoxicity, endocrinopathies, and much more rarely, pneumonitis. Case Presentation: An 80-year-old with past medical history of bronchial asthma, hypertension, 30 pack year smoking history discontinued over 2 decades ago, and metastatic melanoma (MM) on neoadjuvant nivolumab presented to our hospital in September of 2020 with 5 days of worsening shortness of breath. He denied any fever, cough, chest discomfort, palpitation, nausea, vomiting, epigastric/abdominal pain, leg pain, or palpitations. He had been diagnosed with stage IIIc MM in March of 2020 and underwent surgical resection of his left hallux and had completed 5 cycles of immunotherapy with Nivolumab. On admission, the patient had sinus tachycardia to 115, respiratory rate of 18 bpm, normotensive, oxygen saturation 80% on room air, improved to 94% on 4L nasal cannula. Laboratory studies were remarkable for acute kidney injury with Creatinine 1.7mg/dl (1.1 baseline), procalcitonin less than 0.05 ng/dl, elevated D-Dimer to 2.6mg/L, complete blood count, and comprehensive metabolic panel unremarkable. Viral serologies and sputum cultures resulted negative. Chest x-ray demonstrated extensive multifocal bilateral airspace. CTPA revealed severe diffuse bilateral airspace disease concerning for infectious, versus noninfectious pneumonia or a neoplastic process. He subsequently underwent bronchoscopy with BAL of RLL/LLL and RLL brush biopsy, which was negative for malignancy and infectious etiologies, including COVID-19. The patient was diagnosed with grade 3 nivolumab induced pneumonitis, and treated with high dose steroids, and empiric antibiotics. His condition improved, steroids were tapered, and he was discharged on day 13. Discussion: Pneumonitis is a rare, life-threatening complication in patients being treated with nivolumab. When severe symptoms are present and hospitalization and oxygen supplementation are indicated, treatment includes discontinuation of the immunotherapy agent, high dose steroids, prophylactic antibiotics, and additional immunosuppressive therapy if no response to During the midst of a global pandemic, findings of multifocal pneumonia are presumed to be SARS-CoV-2 until proven otherwise. Despite the burden many physicians have faced amid the COVID-19 pandemic, maintaining a broad differential until the diagnosis is made for accurate treatment.