{
  "abstract": "Introduction: Immune checkpoint inhibitors (ICIs) have revolutionized treatment of multiple malignancies, nevertheless, their clinical use can be associated with adverse events (AE). ICI-induced cholangitis (ICI-C) belongs to rare AEs. Poor response to glucocorticosteroids (GCS) is observed, deaths related to ICI-C were reported.\n\nMain findings and therapeutic interventions: We share four detailed cases (two males and two females) of severe ICI-C (severity assessed based on DILIN criteria). All patients were jaundiced (bilirubin >90 µmol/L), one had cholestatic liver injury, two had mixed liver injury and one had a rather hepatocellular liver injury based on R factor in DILI. Three were treated with programmed cell death protein (anti-PD1) or ligand 1 antibodies, one with anti-PD1 and cytotoxic T-lymphocyte-associated protein-4 antibodies. Onset of liver injury was observed during treatment (2), three weeks after last infusion (1) and four months after last treatment (1). Laboratory tests excluded infections, malignant infiltration and autoimmune profile was typically negative. Another drug induced injury was excluded. MRCP and EUS were used as imaging methods of choice. A liver biopsy was organized due to absent response to corticosteroids and second line immunosupressive medication, as cholangitis was suspected. Histology was confirmatory for ICI-C in all cases. Predominant infiltration by CD8 positive lymphocytes was shown. Treatment with tocilizumab, anti-IL-6 receptor antibody, and ursodeoxycholic acid were used in three cases.\n\nOutcomes: Three patients with ICI-C confirmed histologically received tocilizumab and ursodeoxycholic acid with an excellent effect. Decrease in bilirubin was observed within 72 hours. Significant improvement/normalization of liver enzymes followed. No side effects of tocilizumab were reported. Patient who did not receive tocilizumab (maximum bilirubin 349 µmol/L, encephalopathy; cholestatic liver injury – R factor 0.8) died.\n\nConclusion: We advocate for urgent work-up including early liver biopsy the more that immune mediated liver injury from checkpoint inhibitors can cause different laboratory pictures including mixed ones as well as hepatocellular injury (if assessed by DILIN) and still ICI-C can be confirmed on histology. Treatment with tocilizumab, in combination with ursodeoxycholic acid, can be considered in severe cases of ICI-C.",
  "abstract_shown": true,
  "affiliations": [
    "The Royal Marsden Hospital NHS Foundation Trust",
    "Imperial College Healthcare NHS Trust",
    "Royal Free Hospital NHS Foundation Trust"
  ],
  "article_type": null,
  "arxiv": null,
  "author_total": 20,
  "authors": [
    {
      "affs": [
        0
      ],
      "name": "Darina Kohoutova"
    },
    {
      "affs": [
        0
      ],
      "name": "Joshua Shur"
    },
    {
      "affs": [
        0
      ],
      "name": "Monica Terlizzo"
    },
    {
      "affs": [
        1
      ],
      "name": "Robert Goldin"
    },
    {
      "affs": [
        0
      ],
      "name": "Matthew Foxton"
    },
    {
      "affs": [
        0,
        1
      ],
      "name": "Nicholas Powell"
    },
    {
      "affs": [
        2
      ],
      "name": "Douglas Macdonald"
    },
    {
      "affs": [
        0
      ],
      "name": "Naureen Starling"
    },
    {
      "affs": [
        0
      ],
      "name": "Sheela Rao"
    },
    {
      "affs": [
        0
      ],
      "name": "Kevin Joseph Harrington"
    },
    {
      "affs": [
        0
      ],
      "name": "Kate Young"
    },
    {
      "affs": [
        0
      ],
      "name": "Sanjay Popat"
    },
    {
      "affs": [
        0
      ],
      "name": "Nicos Fotiadis"
    },
    {
      "affs": [
        0
      ],
      "name": "Edward W. Johnston"
    },
    {
      "affs": [
        0
      ],
      "name": "Sameer Zar"
    },
    {
      "affs": [
        0
      ],
      "name": "Daniel Levine"
    },
    {
      "affs": [
        0
      ],
      "name": "Maroua Hafi"
    },
    {
      "affs": [
        0
      ],
      "name": "Pablo Jimenez-Labaig"
    },
    {
      "affs": [
        0
      ],
      "name": "Abu Taher"
    },
    {
      "affs": [
        0
      ],
      "name": "David C. Cunningham"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/54y5s58xanv1p.bib",
  "cited_by": 0,
  "doi": "10.3389/fimmu.2026.1929147",
  "fulltext_url": null,
  "id": "54y5s58xanv1p",
  "issns": [
    "1664-3224"
  ],
  "landing_url": "https://www.frontiersin.org/articles/10.3389/fimmu.2026.1929147/full",
  "language": null,
  "licence": "CC-BY-4.0",
  "licence_label": "CC BY 4.0",
  "licence_source": "article",
  "licence_url": "https://creativecommons.org/licenses/by/4.0/",
  "metadata_licence": null,
  "native_subjects": [
    [
      "openalex",
      "2730|Cancer Immunotherapy and Biomarkers"
    ]
  ],
  "openalex": "W7223982280",
  "pdf_url": "https://www.frontiersin.org/journals/immunology/articles/10.3389/fimmu.2026.1929147/pdf",
  "pmcid": null,
  "pmid": null,
  "published": "2026-10-27",
  "publisher": "Frontiers Media SA",
  "ris": "https://research.draconitic.com/paper/54y5s58xanv1p.ris",
  "sources": [
    {
      "first_seen": "2026-10-30T12:19:17Z",
      "native_id": "10.3389/fimmu.2026.1929147",
      "source": "crossref",
      "url": "https://www.frontiersin.org/articles/10.3389/fimmu.2026.1929147/full"
    }
  ],
  "subjects": [
    {
      "field": "medicine",
      "origin": "openalex:2730|Cancer Immunotherapy and Biomarkers",
      "subfield": "oncology"
    }
  ],
  "title": "Case Series: Severe cholangitis as an immune checkpoint inhibitor induced adverse event in four cases: management and treatment options including tocilizumab and ursodeoxycholic acid",
  "title_text": "Case Series: Severe cholangitis as an immune checkpoint inhibitor induced adverse event in four cases: management and treatment options including tocilizumab and ursodeoxycholic acid",
  "type": "peer-reviewed",
  "updated_at": "2026-10-30T12:19:17Z",
  "url": "https://research.draconitic.com/paper/54y5s58xanv1p",
  "venue": "Frontiers in Immunology",
  "versions": []
}