Cardiac tamponade and adrenal insufficiency due to pembrolizumab: a case report

Abstract

Introduction: Patients who receive or have received anti-programmed cell-death-1 (PD-1) monoclonal antibodies can develop immune-related adverse events due to activation of the immune system.

Case presentation: We report a case of a patient who received pembrolizumab and presented with cardiac tamponade. Despite pericardial drainage, she persisted with refractory arterial hypotension due to secondary adrenal insufficiency. After initiating corticosteroid therapy, the patient recovered successfully.

Discussion: The association of pericarditis, hypophysitis and thyroid dysfunction support the diagnosis of a life-threatening immune-related adverse event due to pembrolizumab. In case of immune-related adverse events secondary to anti-PD-1 monoclonal antibodies, corticosteroid therapy should be promptly initiated in order to avoid major complications.

Keywords: Adrenal insufficiency; Cardiac tamponade; Case report; Corticosteroids; Pembrolizumab; Pericarditis.

Figure 1

(A) Pulsed Doppler recording of left ventricular inflow showing reduced early diastolic filling with inspiration. (B) Pulsed Doppler recording of pulmonary vein flow showing a prominent diastolic filling phase. (C) Subcostal view showing a dilated inferior vena cava reflecting the elevated right atrial pressure. (D) Pulsed Doppler recording of hepatic vein flow showing increased hepatic vein flow reversal with expiration.

Figure 2

(A) Acute pericarditis, haematoxylin, and eosin staining. (B) CD3+ infiltrated in the pericardium. (C, D) Huge infiltration in pericardium with predominance of neutrophils, although there are some lymphocytes.

Figure 3

(A) Four-chamber and (B) two-chamber end-diastole cine-RM images show a thickened pericardium without pericardial effusion (arrows). Note mild bilateral pleural effusion (asterisks). (C) Four-chamber short-tau inversion recovery (STIR) T2-weighted imaging shows diffuse pericardial hyperintensity suggesting pericardial oedema (arrows) and (D) two-chamber delayed-contrast-enhanced imaging depicts diffuse pericardial enhancement (arrows) indicating pericardial inflammation.