Case Report
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Jan 6, 2023; 11(1): 218-224
Published online Jan 6, 2023. doi: 10.12998/wjcc.v11.i1.218
Pembrolizumab-induced psoriatic arthritis treated with disease-modifying anti-rheumatic drugs in a patient with gastric cancer: A case report
Sehan Kim, Jong Hee Sun, Hongsik Kim, Hee Kyung Kim, Yaewon Yang, Jun Su Lee, In Ah Choi, Hye Sook Han
Sehan Kim, Jong Hee Sun, Hongsik Kim, Hee Kyung Kim, Yaewon Yang, Department of Internal Medicine, Chungbuk National University Hospital, Cheongju 28644, South Korea
Jun Su Lee, Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, South Korea
In Ah Choi, Hye Sook Han, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju 28644, South Korea
Author contributions: Kim S, Sun JH, and Kim H contributed to manuscript writing and data collection; Kim HK, Yang Y, Lee JS, and Choi IA contributed to manuscript editing and data collection; Han HS contributed to conceptualization and supervision; all authors have read and approved the final manuscript.
Informed consent statement: Informed written consent was obtained from the patient for publication of this case report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflict of interest to disclose.
CARE Checklist (2016) statement: The authors have read the CAER Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Hye Sook Han, MD, Professor, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, No. 1 Chungdae-ro, Seowon-gu, Cheongju 28644, South Korea. hyesukhan@chungbuk.ac.kr
Received: October 16, 2022
Peer-review started: October 16, 2022
First decision: November 4, 2022
Revised: November 10, 2022
Accepted: December 16, 2022
Article in press: December 16, 2022
Published online: January 6, 2023
Abstract
BACKGROUND

Immune checkpoint inhibitor (ICI)-induced rheumatic immune-related adverse events (irAEs) have been infrequently reported, and the treatment of severe or refractory arthritis as irAEs has not been established yet.

CASE SUMMARY

The patient was a 67-year-old man with a history of well-controlled foot psoriasis who presented with polyarthralgia. He had received pembrolizumab for metastatic gastric adenocarcinoma 2 mo previously. Physical examination revealed erythematous swelling in the distal interphalangeal joints, left shoulder, and both knees. He had plaque psoriasis with psoriatic nail dystrophy and dactylitis in the distal joints of the fingers and toes. Inflammatory markers including C-reactive protein and erythrocyte sedimentation rate were elevated but rheumatoid factor and anticyclic citrullinated peptide antibody were negative. The patient was diagnosed with psoriatic arthritis (PsA) and started on methylprednisolone 1 mg/kg/day after pembrolizumab discontinuation. However, despite 1 wk of methylprednisolone treatment, PsA worsened; hence, leflunomide and methotrexate were started. After 4 wk of steroid treatment, PsA worsened and improved repeatedly with steroid tapering. Therefore, the therapy was intensified to include etanercept, a tumor necrosis factor inhibitor, which ultimately resulted in adequate PsA control.

CONCLUSION

This is the first report of ICI-induced PsA in a gastric cancer patient. Some rheumatic irAEs with refractory severe arthritis may require disease-modifying anti-rheumatic drugs and long-term management.

Keywords: Pembrolizumab, Psoriatic arthritis, Disease-modifying anti-rheumatic drugs, Gastric cancer, Case report

Core Tip: Although immune checkpoint inhibitors are being used increasingly and widely, a fair percentage of patients treated with these drugs experience immune-related adverse events (irAEs). Arthralgia and skin lesions are among the most frequent irAEs. However, rheumatic irAEs are underreported and/or misclassified and have been poorly characterized. These rheumatic irAEs are different in simple arthralgia or cutaneous irAEs that they may be requiring long-term management and disease-modifying anti-rheumatic drugs in severe or refractory case. We report a first case of pembrolizumab-induced psoriatic arthritis that was treated with tumor necrosis factor-α inhibitors in a patient with gastric cancer and discuss the treatment course.