Pneumonitis – Grade 2

Management escalation pathway

Withhold ICPi

  • Monitor symptoms: hospitalize patient in case of doubt
  • Start antibiotic if suspicion of infection (fever, CRP, neutrophil counts, purulent sputa)
  • If no evidence of infection or no improvement with antibiotics after 48h add (methyl)prednisolone 1 mg/kg/day orally
  • If no improvement after 48h of oral prednisolone, manage as per Grade 3
  • Consider Pneumocystis prophylaxis depending on the clinical context (especially in immunosuppressed and lymphopenic patients)

Assessment and Investigations

  • High resolution CT
  • Regular blood analysis including CRP
  • Analyse sputum sample (incl screening for viral, opportunistic or specific bacterial infections (mycoplasma, legionella))
  • Discuss bronchoscopy and BAL with pneumologist
  • Perform lung function tests, including TCLO
Check in medical history
  • Underlying cardiac or respiratory disease: pulmonary hypertension, connective tissue disease (eg preexisting interstitial lung disease)
  • Past or ongoing infectious diseases: HIV, Influenza, Mycobacterium Tuberculosis exposure
  • Smoking, travel and allergens history (including exposure to home occupational aeroallergens)
  • Discuss previous exposure to thoracic radiotherapy with radiotherapist
Differential Diagnosis
  • other causes of pneumonia (including atypical pneumonia, Pneumocystis, Tuberculosis, …)
  • Carcinomatous lymphangitis
  • Pulmonary oedema
  • Pulmonary emboli
  • Sarcoidosis
Steroid weaning upon symptom control
  • Grade 2: wean oral steroids over at least 6 weeks, titrate to symptoms
  • Grade 3/4: wean steroids over at least 8 weeks (evaluate with CT scan)

Caution during steroid treatment:

  • Calcium & vitamin D supplementation as per local guidelines
  • Pneumocystis prophylaxis to be considered: Cotrimoxazol 480mg 3 times a week
Restart immunotherapy
  • Should be discussed multidisciplinary among oncologist and pneumologist  patient should be included in risk assessment (only 7 out 10 cases of pneumonitis had a relaps of pneumonitis upon ICPI restart
  • Only indicated once steroids are completely weaned and CT lung is completely cleared


ICPi: Immune Checkpoint Blockade Inhibition
ARDS: Acute Respiratory Distress Syndrome
CRP: C Reactive Protein
ULN: Upper Limit of Normal
TFT: Thyroid Function Test
TCLO: Transfer Factor for Carbon Monoxide
MMF: Mycophenolate mofetil