Very late presentation of fulminant myocardial immune-related toxicity in a patient on pembrolizumab

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Conference Proceeding

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J Am Coll Cardiol


Background Immune checkpoint inhibitors (ICI) can manifest as toxicity in the form of autoimmune, breakthrough or immune-related adverse events. Case A 59-year-old woman presented with worsening dyspnea on exertion for 1 week. Her medical history was significant for non-small cell lung carcinoma treated with pembrolizumab for 6 months. At presentation, she was hypotensive and hypoxic. Electrocardiogram (EKG) revealed complete heart block. Echocardiogram demonstrated severely reduced left ventricular systolic function (LVEF 18% down from 70%). Emergent coronary angiogram showed normal coronary arteries. Cardiac magnetic resonance (CMR) was suggestive of toxic myocarditis. Patient was immediately started on high-dose IV steroids. Decision-making We report a very late presentation of ICI-associated myocarditis complicated by complete heart block and acute systolic heart failure. CMR showed extensive left ventricular late gadolinium enhancement and edema suggestive of toxic myocarditis (yellow arrows); T2 mapping sequences demonstrated prolonged T2 relaxation time consistent with extensive edema (green and red areas). Despite aggressive therapy, her LVEF did not improve on follow-up echocardiograms and she died 6 months later. Conclusion Myocardial immune toxicity is a rare adverse effect of ICI. Early recognition and treatment of left ventricular dysfunction is imperative in this vulnerable population.





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