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Immune-related Adverse Events from Immune Checkpoint Inhibitor Therapy

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53 Table 7. Nervous System Toxicities 7.6 Encephalitis Workup/Evaluation • Neurologic consultation. • MRI brain with/without contrast may reveal T2/FLAIR changes typical of what is seen in autoimmune encephalopathies or limbic encephalitis or may be normal. • 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, PCR for HSV and other viral PCRs depending on suspicion, oligoclonal bands, autoimmune encephalopathy, and paraneoplastic panels. • May see elevated WBC with lymphocytic predominance and/or elevated protein. • EEG to evaluate for subclinical seizures. • Serum studies: Chem panel, CBC, ESR, CRP, ANCA (if suspect vasculitic process), thyroid panel including thyroid peroxidase (TPO) and thyroglobulin, am cortisol and ACTH, GQ1b antibodies (Bickerstaff encephalitis, rhomboencephalitis), celiac antibody panel, paraneoplastic and autoimmune encephalitis panels. • Rule out concurrent anemia/thrombocytopenia, which can present with severe headaches and confusion. 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. • As above for aseptic meningitis suggest concurrent IV acyclovir until PCR results obtained and negative. • Trial of methylprednisolone 1–2 mg/kg/day. • Neurolog y consultation • If severe or progressing symptoms or oligoclonal bands present, consider pulse corticosteroids (methylprednisolone 1 gram IV daily for 3–5 days) plus IVIG 2 g/kg over 5 days (0.4 g/kg/ day) or plasmapheresis. • Taper steroids following acute management over at least 4–6 weeks. • If positive for autoimmune encephalopathy or paraneoplastic antibody or limited or no improvement, consider Rituximab in consultation. • Admit patient 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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