Raising awareness of immune-related side effects in oncological patients under palliative care: a report of two cases.

BACKGROUND: Immune checkpoint inhibitors (ICI) have emerged as a successful treatment option for diverse cancer entities. However, ICI therapy can be associated with immune-related adverse events (irAE) that can affect any organ system. These side effects can be severe, irreversible and sometimes even fatal. Due to the presentation as diverse and often unspecific clinical patterns, end-of-life care concepts may be pursued hastily suspecting disease progression in oncological patients receiving palliative care (PC). CASE DESCRIPTION: This report describes two cancer patients whose symptom burden was caused by such irAEs: One patient with metastatic cutaneous squamous cell carcinoma (SCC) presenting with disorientation and urinary incontinence, another patient with metastatic melanoma presenting with a sudden and unspecific deterioration of the overall condition. After imaging and blood sampling, an encephalitis and an immune-mediated diabetes mellitus were diagnosed. After treatment with corticosteroids and hydration alongside insulin substitution both patients experienced a complete symptom relief. CONCLUSIONS: We aim to emphasize the importance of continued collaboration between primary care givers and PC teams as well as raise awareness among PC providers of severe immune-related side effects in cancer patients receiving ICI. Especially within this patient cohort, PC teams play a crucial part in detecting possible irAEs, which resolve in the majority of cases when receiving early guideline-adapted treatment.

Metabolic Syndrome in Psoriasis Is Associated With Upregulation of CXCL16 on Monocytes and a Dysbalance in Innate Lymphoid Cells.

Psoriasis is frequently associated with the metabolic syndrome and occurs more often in obese individuals. In order to understand innate immune mechanisms mediating this inflammatory pattern we investigated expression of the chemokine and lipid scavenger receptor CXCL16 in patients with psoriasis and associated comorbidities. CXCL16 expression was enhanced on all monocyte subsets in psoriatic patients compared with healthy controls and positively correlated with psoriasis activity and severity index, body mass index and the risk for cardiovascular disease indicated by PROCAM score. The intensity of CXCL16 expression on monocytes further correlated with their capability to phagocytose oxidized LDL indicating the possibility to transform into foam cells in atherosclerotic plaques. Patients with psoriasis and atherosclerosis or obesity displayed elevated numbers of innate lymphoid cells in blood with specific increase of the IFN-γ or IL-17 producing ILC1 and ILC3 subpopulations. The expression of the CXCL16 receptor, CXCR6, was increased in ILCs and co-expressed with CCR6 but not CCR7 indicating their migratory potential to psoriatic skin or adipose tissue that is characterized by strong CXCL16 and CCL20 expression. This hypothesis was supported by the finding that the percentage of CXCR6 expressing ILCs was alleviated in blood of psoriatic patients. Together these data link a strong expression of CXCL16 to metabolic syndrome in psoriasis and indicate a possible link to ILC activation and tissue distribution in obese psoriatic patients. These data contribute to the understanding of the complex interaction of innate immunity and metabolic state in psoriasis.

Cortisol reactivity in social anxiety disorder: A highly standardized and controlled study.

In order to understand the psychopathology of the social anxiety disorder (SAD) at the neuroendocrine level, standardized experimental studies on endocrine and physiological markers are necessary, especially since empirical data are still ambiguous. Hence, differences in both, the autonomic nervous system (ANS) and the endocrine stress responses (ACTH, salivary and plasma cortisol) were investigated in a particularly homogenous sample after a standardized stressor (Trier Social Stress Test). The sample consisted of n = 35 patients with SAD, age, and gender matched to n = 35 healthy controls (HC). In terms of the heart rate, the response pattern was comparable in both groups. Concerning ACTH, no significant group differences in the response pattern nor in the total output (AUCG) were exhibited. Significant differences were noticeable only in the plasma cortisol response pattern with less total output (AUCG) in patients suggesting a blunted response. The salivary cortisol response indicated comparable patterns between groups. However, the patients' total output (AUCG) was significantly smaller relative to the controls. In sum, evidence for a hypo-responsiveness of the HPA-axis in SAD by means of blood cortisol was observed, with no differences in ACTH between the two groups. This reduced reactivity of the HPA-axis might be associated with an inability to elicit an adequate hormone release, possibly accompanied by an enhanced perception of the stress stimulus. This might be explained by an adaptation of the adrenocortical system due to prolonged repeated stress exposure such as social evaluation.