Resolution of ipilimumab induced severe hepatotoxicity with triple immunosuppressants therapy

Summary

We describe a case of a patient from Far North Queensland, Australia, with life-threatening hepatotoxicity caused by ipilimumab induced immune-related adverse events (irAEs). Our patient presented with non-specific symptoms including malaise, lethargy and fevers. Her work up revealed acute hepatitis, which was presumed to be related to ipilimumab treatment for her metastatic melanoma. Causality for ipilimumab was assessed with the CIOMS scale (Council for International Organizations of Medical Sciences) and provided a causality level of ‘highly probable’ (score +9). She was started on methylprednisolone as per guidelines for ipilimumab induced irAEs. On the second day of treatment her transaminases enzymes unexpectedly rose several hundred times. Investigations for other causes of acute hepatitis including abdominal imaging were negative. She was started up front on equine antithymocyte globulin, mycophenolate moefetil and continued on methylprednisolone. She recovered clinically and biochemically in 2 weeks and continues to remain well.