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irAE PRCA — SCE Medical Oncology MCQ

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HardMelanoma & SkinirAE PRCASCE Medical Oncology

A 65-year-old man with advanced melanoma on nivolumab develops immune-related pure red cell aplasia (PRCA). Reticulocyte count is 0. CK is normal. DAT is negative. Parvovirus B19 PCR is negative. What is the management?

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Correct answer: E — Hold nivolumab, start prednisolone 1 mg/kg; if steroid-refractory consider ciclosporin — PRCA may also require red cell transfusion support

ICI-induced pure red cell aplasia (PRCA) presents with severe anaemia, absent reticulocytes and erythroid hypoplasia on bone marrow (normal myeloid and megakaryocyte lineages). DAT is negative (distinguishing from AIHA). Parvovirus B19 must be excluded (also causes PRCA). Management: ICI discontinuation, prednisolone 1 mg/kg. If steroid-refractory, ciclosporin is the most effective second-line agent for PRCA (targeting T-cell-mediated erythroid suppression). IVIG and mycophenolate are alternatives. Red cell transfusion for symptomatic anaemia.

Reference: ESMO 2024 irAE Management; Michot et al Ann Oncol 2016