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Immune-related Adverse Events from Immune Checkpoint Inhibitor Therapy

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52 Treatment Table 7. Nervous System Toxicities 7.5 Aseptic Meningitis Workup/Evaluation: • MRI brain w/wo contrast with pituitary/sellar cuts protocol. • AM cortisol, ACTH to rule out adrenal insufficiency. • Strongly consider lumbar puncture with CSF analysis for opening pressure, cell count and differential, cytolog y for malignant cells that could indicate leptomeningeal metastases, protein, glucose, gram stain, viral/bacterial cultures, polymerase chain reaction (PCR) for herpes simplex virus (HSV) and other viral PCRs depending on suspicion. • May see elevated WBC in CSF with normal glucose, normal culture and gram stain. May see reactive lymphocytes, neutrophils or histiocytes on cytolog y. Grading Management G1: Mild: no interference with function and symptoms not concerning to patient. Note: any cranial nerve problem should be managed as moderate. • Hold ICPi and discuss resumption with patient only after taking into account the risks and benefits. • Consider neurolog y consult • Consider empiric antiviral (IV acyclovir) and antibacterial therapy until CSF results. • Once bacterial and viral infection negative, may closely monitor off corticosteroids or consider oral prednisone 0.5–1 mg/kg/day or IV methylprednisolone 1 mg/kg/day if moderate/ severe symptoms. • Steroids can be tapered after 2–4 weeks, monitoring for symptom recurrence. • Consider hospitalization for G3–4. G2: Moderate: some interference with ADLs, symptoms concerning to patient (i.e., pain but no weakness or gait limitation). G3–4: Severe: limiting self-care and aids warranted (cont'd)

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