Toxic epidermal necrolysis during chemo-immunotherapy treatment with pembrolizumab

Abstract

Introduction

Immune checkpoint inhibitors (ICIs), such as anti-PD-1/PD-L1 antibodies, improve survival in patients with advanced malignancies. However, their combination with chemotherapy may increase the incidence of severe immune-related adverse events (irAEs), including rare but life-threatening dermatologic toxicities.

Case report

We report the case of a 69-year-old male diagnosed with stage IV squamous cell lung cancer who received first-line treatment with carboplatin, paclitaxel, and pembrolizumab. Two days after the third cycle, he developed non-itching macular lesions which progressively extended to over 90% of the body surface area (BSA) and evolved into large bullous lesions with exudation. Antineoplastic treatment was discontinued and the patient was hospitalized.

Management and outcome

Systemic corticosteroids, antihistamines, and analgesics were initiated, along with topical wound care with steroids and zinc sulphate. Due to the limited response to treatment, etanercept was administered and the patient was transferred to a specialized burn unit, where corticosteroid therapy and topical wound care were continued until re-epithelialization. Eventually, after 16 days of admission, the patient was discharged with a diagnosis of toxic epidermal necrolysis (TEN) secondary to immunotherapy.

Discussion

SJS/TEN are rare, life-threatening cutaneous adverse reactions potentially triggered by ICIs. Management involves prompt identification and discontinuation of the offending drug, initiation of supportive measures, and meticulous skin care. The use of systemic corticosteroids remains controversial. TNF-α inhibitors, such as etanercept, have shown efficacy in different studies, but additional trials are needed to confirm these findings. This case highlights the importance of early recognition and multidisciplinary management of severe ICI-induced dermatologic toxicity.