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irAE Encephalitis — SCE Medical Oncology MCQ

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HardImmunotherapy & Targeted TherapyirAE EncephalitisSCE Medical Oncology

A 60-year-old woman on combination ICI develops immune-related encephalitis. MRI brain shows bilateral mesial temporal lobe enhancement. CSF shows lymphocytic pleocytosis and elevated protein. What is the management?

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Correct answer: E — Permanently discontinue ICI, start high-dose IV methylprednisolone 1-2 mg/kg (or pulse 1 g/day for severe cases), consider IVIG or plasma exchange, neurology urgent review, exclude infection and leptomeningeal disease

ICI-induced limbic/autoimmune encephalitis presents with confusion, memory impairment, seizures and personality changes. MRI may show bilateral mesial temporal lobe T2/FLAIR hyperintensity. CSF shows lymphocytic pleocytosis. Management requires: ICI permanent discontinuation, high-dose IV corticosteroids, and consideration of IVIG/plasmapheresis for severe or steroid-refractory cases. HSV encephalitis must be excluded (PCR) and empiric aciclovir given until viral causes are ruled out. Anti-neuronal antibodies (NMDA-R, LGI1, CASPR2) should be tested.

Reference: ESMO 2024 irAE Management; Cuzzubbo et al Eur J Cancer 2017; ASCO Neuro irAE Guidelines