IMMUNOTHERAPY INDUCED MYOCARDITIS
Recommended Citation
Yaseen A, Loutfi R. IMMUNOTHERAPY INDUCED MYOCARDITIS. 2022; :S468-S469.
Document Type
Conference Proceeding
Publication Date
6-17-2022
Abstract
CASE: 76-year-old male with past medical history significant for Renal cell carcinome status post right nephrectomy in 2019 with metastases in lungs and spine found on CT scan in 2020. Patient was started on immunotherapy with a combination of ipilimumab/ nivolumab. On the day of his scheduled fourth cycle, he presented with shortness of breath on exertion, generalized weakness and decreased right hand grip strength. Physical exam was remarkable for upper and lower extremity proximal muscle weakness along with weak hand grip Workup was remarkable for troponin 9677 ng/L, ALT/AST of 337/488 IU/L respectively, CPK 3934 IU/L, TSH 2.77 IU/ml, Cr 2.09 mg/dl, BNP 76 .CXR demonstrated opacities in the left lower lobe representing pleural effusion vs atelectasis, CT Head, EKG were normal. Echocardiogram showed a reduced EF of 40 %. Left heart catheterization was unremarkable. He was diagnosed with Immune Checkpoint Inhibitor Associated Serious Adverse Event, and per ASCO guidelines, he was diagnosed with grade 3 myocarditis. He received supportive care and IV solumedrol 1 g/d. Over 5 days, troponins, CPK, ALT/AST and kidney function all improved significantly. Patient was discharged on oral prednisone (150 mg daily) with an outpatient taper. Immunotherapy was discontinued indefinitely. IMPACT/DISCUSSION: Immune checkpoint inhibitors (ICI) are a new cancer treatment modality. They inhibit several immune checkpoints and enable the tumor reactive T-cells to overcome the regulatory inhibiting mechanisms promoted by cancer cells, and as a result, T-cells “wake up” and target cancer cells. ICI have a wide range of IrAE (Immune-related adverse events) affecting different organs, with higher incidence reaching 54 % in combination therapy. Our patient presented with multiple organ damage including immune hepatitis (transaminitis) and myositis, but the main focus was the immune-related myocarditis. This is a rare, but potentially fatal, side effect which occurs in up to 1% of patients receiving immunotherapy. It usually occurs within 1-3 months after initiating immune therapy, and in Up to 50% of cases, myocarditis is present on their presentation. Early recognition of symptoms and expeditious treatment are the mainstay of management due to a 25-50% risk of death. Cardiac biomarkers, EKGs, echocardiograms and Cardiac MRI can help in diagnosing and assessing the severity of ICI induced myocarditis. Troponin levels help predict the risk of Major Adverse Cardiac Effect (MACE), where a 4- fold increase in MACE occurs when troponin levels are >1.5 ng/ml. Several national guidelines guide Immune-related myocarditis grading and management. Steroids remain the cornerstone of treatment and often patients would not be able to receive any Immunotherapy in the future, thus limiting patients' treatment options. CONCLUSION: 1- Immunotherapy are becoming more popular with more patients presenting with immunotherapy related side effects. 2- It is important to be familiar with these side effects and management guidelines.
First Page
S468
Last Page
S469
