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Checkpoint Inhibitor Pneumonitis Mimicking Postoperative Complication Following Delayed Autologous Breast Reconstruction
Christopher J. Fedor, Sarah M. Tepe, Hilary Y. Liu, Francesco M. Egro
UPMC, Department of Plastic Surgery, Pittsburgh, PA
Delayed autologous reconstruction offers superior outcomes in patients undergoing post-mastectomy radiation therapy (PMRT), particularly those with a history of smoking, by reducing flap exposure to radiation-induced changes. However, recent immunotherapy use, such as immune checkpoint inhibitors, adds complexity to the perioperative period. Checkpoint inhibitor pneumonitis (CIP), though rare, poses a diagnostic challenge in postoperative patients presenting with respiratory distress, potentially mimicking infectious or surgical complications. A 59-year-old woman with BRCA2+ triple-negative breast cancer, 34 pack-year smoking history, and prior treatment with pembrolizumab, completed neoadjuvant chemoimmunotherapy, bilateral mastectomy, and PMRT. She later underwent delayed autologous reconstruction using a left TRAM flap and a right DIEP flap. On postoperative day 4, she developed hypoxic respiratory failure with escalating oxygen requirements and bilateral infiltrates. Despite initial empiric management for pneumonia and pulmonary embolism, her condition worsened. Given her history, immune checkpoint inhibitor pneumonitis was suspected. High-dose IV steroids were initiated alongside IVIG and mycophenolate mofetil (CellCept), with gradual clinical improvement. She remained in the ICU for 18 days and was ultimately discharged on a steroid taper and home oxygen. This case highlights the importance of maintaining a high index of suspicion for immune-related adverse events in the microsurgical reconstruction population, particularly those with prior checkpoint inhibitor exposure. Postoperative respiratory decompensation in these patients should not be assumed to be infectious, anesthetic, or flap-related. Multidisciplinary collaboration and early initiation of immunosuppressive therapy are critical for favorable outcomes. Plastic surgeons must account for the evolving oncologic treatment landscape—including immunotherapy—when planning and managing complex breast reconstruction cases.
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