THE TRIPLE M - NEUROMUSCULAR TRIAD WITH IMMUNE CHECKPOINT INHIBITORS - MYOCARDITIS, MYOSITIS, AND MYASTHENIA GRAVIS-LIKE SYNDROME WITH NIVOLUMAB-RELATLIMAB

Document Type

Conference Proceeding

Publication Date

4-1-2025

Publication Title

J Am Coll Cardiol

Keywords

creatine kinase, immune checkpoint inhibitor, nivolumab, nivolumab plus relatlimab, relatlimab, troponin, adult, aged, case report, clinical article, conference abstract, corticosteroid therapy, diagnosis, diplopia, dizziness, drug therapy, electrocardiography, emergency ward, follow up, heart catheterization, heart left bundle branch block, human, low back pain, male, melanoma, metastatic melanoma, myasthenia gravis, myasthenia like syndrome, myocarditis, myositis, non ST segment elevation myocardial infarction, non-obstructive coronary artery disease, ptosis (eyelid), side effect, therapy

Abstract

Background Immune checkpoint inhibitors (ICIs) have shown significant effectiveness against advanced malignancies, including malignant melanoma, but they can lead to life-threatening immune-related adverse events (iRAEs), particularly when used in combination therapies. In May 2024, Relatlimab in combination with Nivolumab was approved for unresectable or metastatic melanoma in patients aged 12 and older. Approximately 60 cases of myocarditis, myositis, and myasthenia gravis-like syndrome associated with various ICIs have been reported, however no cases were reported with Relatlimab or its combination with Nivolumab. Case A 74-year-old male with a history of scalp melanoma on Nivolumab and Relatlimab for three weeks, presented to the emergency department with mid-lower back pain, dizziness, double vision, and right eye droop. Exam findings included right eye complete ptosis and left eye incomplete ptosis with 4/5 hip strength. Initial tests indicated elevated troponin levels and CPK. EKG showing new left bundle branch block. He was managed for concern for NSTEMI. He went for left heart catheterization which revealed non-obstructive coronary artery disease and there symptoms and troponins attriubuted to myocarditis. Neurological evaluation suggested autoimmune myasthenia gravis and myositis due to immunotherapy. Decision-making Following a multidisciplinary meeting, the ICI was stopped, patient was immediately started on high-dose steroids and given IVIG for persistent symptoms with improvement. At three month follow up, there was significant improvement in symptoms and troponin and CPK levels almost back to normal. Conclusion Given the potential severity of myocarditis, myositis, and myasthenia gravis-like syndrome, immediate corticosteroid treatment is recommended upon suspicion, without awaiting a confirmed diagnosis.

Volume

85

Issue

12

First Page

3791

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