Erosive Deforming Inflammatory Arthritis in a Patient With Cervical Adenocarcinoma

C. Nivolumab-induced inflammatory arthritis

Nivolumab is a fully human monoclonal antibody that selectively binds to the programmed cell death 1 (PD-1) receptor on T cells and blocks the interaction with programed cell death ligand 1 (PD-L1) and PD-L2, resulting in T-cell activation and proliferation.¹ The enhanced immune response associated with nivolumab improves antitumor immunity; however, it is also associated with various immune-related adverse events (irAEs). Based on pooled data from clinical trials of nivolumab, the most common irAE was skin related. Gastrointestinal, hepatic, and endocrine systems were among the other systems that were affected.¹

Inflammatory arthritis is a reported irAE associated with nivolumab, with a prevalence of approximately 2%.² Most patients (65%) present with polyarticular inflammatory arthritis with involvement of small and/or large joints.² Many of these patients do not develop autoantibodies like rheumatoid factor or anti-citrullinated peptide antibody and are thus seronegative. In a cohort of 9 patients who developed arthritis during nivolumab therapy, 5 patients progressed to polyarticular arthritis resembling rheumatoid arthritis, without any evidence of autoantibodies or notable bone erosions. These patients required a much higher dose of systemic steroids than those without polyarticular arthritis, and the arthritis persisted for several months after stopping nivolumab.³ In another case series, the authors described patients who developed seropositive rheumatoid arthritis shortly after receiving nivolumab, raising the concern that nivolumab may unmask underlying autoimmunity.⁴ In 1 report, a patient developed deforming arthritis during nivolumab therapy; however, imaging did not reveal erosions or joint damage.⁵