Pembrolizumab
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Oral mucositis: 2 case reports A retrospective study described two men aged 15 years and 88 years, who developed oral mucositis during treatment with pembrolizumab for anaplastic astrocytoma or lung adenocarcinoma [routes not stated; not all dosages stated]. Patient-1: The 15-year-old man, who had a history of anaplastic astrocytoma presented with oral mucositis. He also had epilepsy. Previously, he received local radiation therapy, temozolomide, lomustine for astrocytoma. Subsequently, he started immunotherapy with pembrolizumab 100mg once in 3 weeks, dexamethasone, oxcarbazepine, clobazam, oxycodone/naloxone and morphine. Three weeks after the first dose of pembrolizumab, he developed extensive superficial ulcers with pseudomembrane fibrin coating on tongue (dorsal), bilateral buccal mucosae, palate, superficial mucocele (palate). The lesions were non-lichenoid. He was negative for bacterial and fungal infection. The ulcers caused major pain and eating difficulties. He was diagnosed with pembrolizumab related grade 3 oral mucositis as an immune-related adverse event. The pembrolizumab was discontinued. He received unspecified corticosteroids, tacrolimus, benzydamine and lidocaine. But, he had no beneficial effect with the treatment. Later, he received low-level laser therapy (LLLT). After each laser session his pain considerably reduced for several days. But, he did not have any effect on the clinical appearance (including size) of the lesions. Later, he developed xerostomia. Due to deterioration, he was lost to follow-up after 7 weeks of LLLT and one month later, he died [cause of death not stated]. Patient-2: The 88-year-old man, who had a history of lung adenocarcinoma presented with oral mucositis. He had started immunotherapy with pembrolizumab. He also had prostatic hyperplasia and was also receiving tamsulosin. He was past smoker. Six weeks after the first dose of pembrolizumab, he developed extensive superficial ulcers with pseudomembrane fibrin coating on tongue (lateral, ventral and dorsal), bilateral buccal mucosae, labial mucosae. He was also positive for Candida infection. Biopsy of the lesion revealed squamous mucosa with ulceration and moderate acute and chronic inflammation; lichenoid pattern was not noticed. Direct immunofluorescence showed deposition of IgA forming cytoid bodies in the submucosa. Therefore, he was diagnosed with pembrolizumab associated grade 3 oral mucositis. The pembrolizumab was discontinued. He started receiving mouthwash containing lidocaine, dexamethasone and nystatin, followed by clobetasol [clobetasol propionate]. He had a marked improvement with the treatment. He had oral mucositis for 30 weeks in total. Later, he died [cause of death not stated]. Amy DPB, et al. Severe chronic nonlichenoid oral mucositis in pembrolizumab-treated patients: New cases and a review of the literature. Immunotherapy 12: 777-784, No. 11, 803507165 Aug 2020. Available from: URL: http://doi.org/10.2217/imt-2019-0162
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