Onychopathy induced by Nivolumab: a focused immunotherapy

Nivolumab is a human immunoglobulin G4 (IgG4) monoclonal antibody that binds to the PD-1 receptor on T cells and blocks its interplay with PD-L1 and PD-L2, releasing inhibition of the immune response mediated by PD-1 pathway, together with the anti-tumor immune response, leading to decreased tumor progress. Right here we current the case of a 56-year-old girl with a analysis of squamous cell carcinoma (SCC) of the lip who introduced with dystrophy of 20 nails, distal onycholysis, yellow-black discoloration of the plates of the nail, painful paronychia with bacterial an infection of the massive toes of each toes for 3 months. Just a few warty growths had been additionally appreciated on the massive toes of each toes. She had undergone for her SCC 33 periods of radiotherapy and 43 cycles of nivolumab 140mg for 60 minutes each two weeks. After discontinuation of this drug, the periungual and nail mattress irritation improved, however the nail plate dystrophy persevered. To our information, the prevalence of nail dystrophy with nivolumab has by no means been reported earlier than but it surely has been described with different focused therapies.


Nivolumab is a focused immunotherapy that works by blocking the human programmed demise receptor-1 (PD-1) on T cells [1]. It’s used within the remedy of many cancers, for instance recurrent or metastatic squamous cell carcinoma of the top and neck, metastatic melanoma, metastatic small cell lung most cancers, superior and metastatic cancers of the esophagus, gastrointestinal and renal system. Its widespread unwanted effects embrace fatigue, lymphocytopenia, decreased urge for food, and cough. Much less widespread unwanted effects embrace nausea, stomach ache, constipation, fever, rash, immune-mediated hypothyroidism and hyperthyroidism, colitis, nephritis, pneumonitis, and hepatitis. It additionally ends in an electrolyte imbalance. Nivolumab is a class D drug for being pregnant and is harmful to the fetus, so women and men are suggested to not conceive whereas taking this drug and 5 months after stopping this drug. Some of these unwanted effects have additionally been seen with different focused therapies, particularly trastuzumab and alemtuzumab [2]. To our information, just one different case of nail dystrophy as a aspect impact of focused remedy has been reported. [3]. Due to this fact, we report the case of the girl who developed nail dystrophy as a aspect impact of nivolumab mistaken for lip squamous cell carcinoma.

Presentation of the case

A 52-year-old housewife, identified with lip squamous cell carcinoma, taking nivolumab IV for 2 years, introduced to the dermatology ward at Shifa Hospital, Pakistan Naval Station (PNS), Karachi , with complaints of painful lesions in and across the giant nails of each toes with blackish discoloration for 3 months. Bodily examination revealed irritation of the good toe nail fold of each toes together with yellow-black discoloration of the nail plate, distal onycholysis, and frank oozing of pus (Determine 1).

Just a few warty growths had been additionally appreciated on the uncovered a part of the nail matrix. The opposite fingernails and toenails had been additionally discolored. The affected person was identified with a case of squamous cell carcinoma on the left aspect of the decrease lip in 2015. Tumor resection was carried out adopted by 33 radiation remedy periods. After the resection surgical procedure, the affected person was on a liquid weight loss plan as a result of her mouth actions had been restricted. Tumor recurrence occurred in 2019 and the affected person was began chemotherapy nivolumab 140mg each different week. She had taken 43 cycles of nivolumab. She developed nail plate dystrophy of each fingernails and toenails with superimposed bacterial an infection and continual painful paronychia of each massive toes. Nivolumab cycles had been stopped after she developed nail modifications. Her pus pattern was additionally taken for tradition and sensitivity, which examined constructive for Staphylococcus aureus. His hemoglobin (Hb) was 8.2 g/dl, platelet depend 155,000 per microliter of blood, erythrocyte sedimentation charge (ESR) was 55, chest X-ray, kidney operate checks, i.e. serum creatinine, urea, electrolytes and conjugate liver operate checks (direct bilirubin), SGOT (aspartate aminotransferase [AST]), SGPT (alanine aminotransferase [ALT]), alkaline phosphatase, whole protein, albumin and globulin had been regular. The affected person was handled with an antibiotic amoxicillin/clavulanic acid and analgesics and a day by day pyodine-iodine dressing for 2 weeks and known as for follow-up. After two weeks the irritation resolved and a biopsy of the warty progress of the left massive toe nail was taken. Histopathological examination revealed marked epidermal hyperkeratosis, neutrophil crusting, hypergranulosis, acanthosis, and papillomatosis. The higher dermis confirmed a combined inflammatory infiltrate composed of lymphocytes, plasma cells and neutrophils. There was no proof of viral warts or granuloma or malignancy and the report steered acute or continual irritation. The extreme irritation in and across the giant fingernails subsided a few month after stopping nivolumab. Nonetheless, it recurred after drug resumption and subsided after drug discontinuation (Figures 2, 3).

Throughout her remedy, she additionally skilled different unwanted effects from the drug like hypothyroidism for which her physician began taking thyroxine in 150 mcg tablets. She additionally suffered from fatigue, nausea, decreased urge for food and low sodium.


Nivolumab is a human monoclonal antibody that blocks the interplay between PD-1, PD-L1 and PD-L2. Binding of those ligands to the PD-1 receptor current on T cells inhibits T cell proliferation and cytokine manufacturing, leading to decreased tumor progress. A number of unwanted effects of focused therapies have been reported [4]. The commonest aspect impact skilled by sufferers taking nivolumab is fatigue, low sodium, lymphopenia, cough and decreased urge for food. Much less widespread are nausea, vomiting, diarrhea, and electrolyte imbalance; our affected person additionally suffered from a number of unwanted effects and related unwanted effects have been reported with different focused therapies. For instance, diarrhea, anemia, and neutropenia had been most typical in sufferers taking pertuzumab and trastuzumab as outlined by von Minckwitz et al. [5]. The affected person described on this case report had nail plate dystrophy with distal onycholysis and extreme irritation in and round each giant nails. No such unwanted effects have been reported earlier than. Nonetheless, in a current examine in 2021, a uncommon and unconventional aspect impact of nivolumab was reported in a case report by which bluish-gray nail discoloration was induced because of using nivolumab. In keeping with this report, the method by which nivolumab prompted this aspect impact stays to be clarified. [6]. One other report, particularly “Nivolumab-induced pores and skin opposed results” additionally make clear nivolumab-induced pores and skin toxicity and claimed that particular pores and skin toxicity has been poorly reported within the literature. [7]. Immunotherapy is the newest in most cancers drug improvement that has immunomodulatory therapeutic antibodies, focusing on inhibitory receptors expressed by CTLA-4 and PD-1 T cells. They’re used to deal with superior stage most cancers with metastases or an unresectable tumor similar to melanoma and lung most cancers [8]. Importantly, there was a case reported in a analysis article with earlier remedy with nivolumab adopted by vemurafenib who developed poisonous epidermal necrolysis (TEN) [9]. As well as, specific analysis and presentation require drug publicity recording, imaging, and pores and skin biopsies. In the meantime, based on different analysis, the unwanted effects of immune checkpoint inhibitors similar to ipilimumab, nivolumab, pembrolizumab and atezolizumab are attributable to heightened immune responses in opposition to the person’s personal tissues. They happen in 64.2% of sufferers and about 10-15% have extra severe situations [10]. Immunotherapy has emerged as a superior methodology within the administration of various malignancies, particularly superior malignancies. Checkpoint inhibitors have had spectacular success. Nonetheless, their use could also be accompanied by nonspecific immune activation resulting in a myriad of autoimmune and autoinflammatory phenomena. [11]. In the meantime, based on one other examine, these medication intervene with distinct mechanistic effectors central to pathogenesis and scale back the rising nonspecific destruction attributable to standard most cancers chemotherapy, nonetheless, focused therapies are nonetheless linked to a variety of dermatological opposed occasions as a result of signaling pathways are shared between malignant cells and regular mucocutaneous tissue [12]. In a nutshell, additional analysis is warranted, as the particular mechanism by which the drug causes such unwanted effects will not be but identified.


Immunotherapy and focused therapies have change into the primary therapies for cancers and tumours. Nivolumab is the primary focus of this text as a result of the case we current used this remedy and had unwanted effects associated to its use. Later, when the drug was stopped, the identical results diminished. The main target of our examine – extreme irritation of the nail mattress and surrounding paronychia in addition to blackish discoloration of the nails – will be described as a uncommon aspect impact of nivolumab. Whereas, going via completely different literature opinions, it’s identified that a number of results happen via focused therapies together with nivolumab. Due to this fact, an essential results of this examine is to indicate the consequences of nivolumab and the management measures that resulted in a discount in nail situation. Nonetheless, the mechanism by which this happens has not but been decided and additional analysis is required to totally perceive the true reason behind the opposed results.

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