A case report of severe pulmonary arterial hypertension after nivolumab, an IgG4 anti-PD1 monoclonal antibody

Pulmonary hypertension has been increasingly reported in association with immunotherapy, but generally lacking invasive haemodynamic confirmation in literature. We present the first case of pulmonary arterial hypertension following nivolumab confirmed with invasive haemodynamic measurements.

A 65-year-old male with gastro-oesophageal adenocarcinoma developed progressive dyspnoea with exertion, decreasing exercise tolerance after receiving nivolumab for seven months. He was admitted with acute hypoxaemic respiratory failure after syncope at home. The patient was diagnosed with pulmonary arterial hypertension (PAH) with pre-capillary aetiology with right heart catheterization (RHC): mean pulmonary artery pressure 49 mmHg, pulmonary capillary wedge pressure 7 mmHg, and cardiac index 1.3 L/min/m². Based on serial echocardiograms, the development of PAH appeared to be associated with nivolumab. The patient died of cardiac arrest 3 days after admission.

Progressive unexplained dyspnoea after receiving programmed cell death protein 1 monoclonal antibody should prompt clinicians to consider PAH and RHC.