Редкие иммуноопосредованные нежелательные явления: клиническая характеристика, подходы к диагностике и лечению

Внедрение иммунотерапии позволило при ряде злокачественных опухолей (ЗНО) значимо увеличить продолжительность жизни пациентов в сравнении с «классической» химиотерапией. Способность иммунотерапевтических препаратов активировать Т-лимфоциты позволяет, с одной стороны, добиться противоопухолевого эффекта, с другой — может приводить к развитию иммуноопосредованных нежелательных явлений (иоНЯ). Наиболее распространенными иоНЯ являются эндокринные (гипо- или гипертиреоз), гастроинтестинальные (колит, гепатит) и дерматологические (зуд, сыпь) реакции. Редкие, но потенциально угрожающие жизни иоНЯ требуют особого внимания.

Особое место занимает перекрестный синдром, включающий миокардит, миастению и миозит, который отличается быстрыми темпами прогрессирования и высокой летальностью. Миокардит проявляется болями в груди, одышкой и тахикардией, с повышением уровня тропонина — важного диагностического маркера. Сопутствующие миозит и миастения гравис проявляются миалгией и слабостью конечностей. Для разрешения этих иоНЯ требуется применение высоких доз глюкокортикостероидов (ГКС) и иногда плазмафереза.

Среди неврологических иоНЯ особо выделяют энцефалит и синдром Гийена-Барре. Энцефалит проявляется различными общемозговыми симптомами: изменениями психического статуса, головной болью, судорогами и т. д. Синдром Гийена-Барре при этом проявляется мышечной слабостью и парестезиями. Диагностика включает люмбальную пункцию, электроэнцефалограмму и ряд лабораторных исследований. Лечение основано на высоких дозах ГКС, при резистентности к ГКС — использование ритуксимаба.

Офтальмологические иоНЯ могут проявляться сухостью глаз, увеитом и невритом зрительного нерва, иногда приводя к серозной отслойке сетчатки. Для диагностики требуется доступность узкоспециализированных методов, таких как офтальмоскопия и оптическая когерентная томография. Лечение включает топические и местные инъекционные ГКС.

Редкие иоНЯ подчеркивают необходимость междисциплинарного подхода в лечении ЗНО, учитывая сложности диагностики и ведения подобных пациентов. Эта проблема становится все более актуальной с расширением показаний к применению иммунотерапии, что требует разработки эффективных методов управления этими особыми и иногда фатальными осложнениями.

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