Successful therapy for autoimmune myocarditis with pembrolizumab treatment for nasopharyngeal carcinoma

Abstract

Immune checkpoint inhibitors (ICIs), including inhibitors of cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4), programmed death-1 (PD-1) and programmed death-ligand 1 (PD-L1) have demonstrated prominent clinical benefits in a variety of cancers and have been rapidly applied to treat a variety of carcinomas such as melanoma, non-small-cell lung cancer, and head and neck cancer. Meanwhile, the occurrence of immune-related adverse events (irAEs) has been increasing. In this case, we report a 45-year-old man with metastatic nasopharyngeal carcinoma suffering from pulmonary fibrosis and myocarditis on the 4th day after receiving pembrolizumab treatment which belongs to anti-PD-1 drugs. Although the endomyocardial biopsy (EMB) could not be performed, the strong temporal association with pembrolizumab treatment and the specific changes of electrocardiograph, echocardiography and cardiovascular magnetic resonance (CMR) suggest that the myocardial injury and edema were related to pembrolizumab-induced myocarditis. With glucocorticoid treatment, the symptoms and myocardium lesion were almost resolved and the patient agreed to tapered chemotherapy with steroid treatment.

Keywords: Fever; immune checkpoint inhibitors (ICIs); immune-related adverse events (irAEs).

Figure 1

ECG images before and after admission in this patient. (A) The baseline ECG on Jun 8th 2018 showing shallow T wave inversion in V5, V6; (B) ECG on D1 showing ST segment elevated 2–3 mm in V1–V3 and deep T wave inversion in I, aVL, V4, V5, V6; (C) ECG on Aug 20th 2018 showing T waves are right way up. ECG, electrocardiogram.

Figure 2

Chest computed tomography scan in this patient. (A) Chest CT showing increasing patchy ground opacities and fibrous stripes of the bilateral lower lobe; (B) fading lesions of bilateral lower lobe.

Figure 3

Cardiovascular contrast-enhanced magnetic resonance findings in this patient. (A,B) Local uneven thickening of LVW and LVPW in T1-weighted images on Aug 16th 2018 and normal LVW on Aug 24th 2018; (C,D) patched myocardial signal intensity increase in T2-weighted FS images on Aug 16th 2018 and the decreasing area of high signal intensity on Aug 24th 2018; (E,F) delayed contrast-enhanced T1 images show a patchy lesion in LV inferior wall and ventricular septum (arrows) on Aug 16th 2018 and evenly diffuse in LV on Aug 24th 2018. LVW, left ventricular wall; LVPW, left ventricular posterior wall; FS, fat suppression; LV, left ventricular.

Figure 4

Clinical Course of this patient with autoimmune myocarditis caused by pembrolizumab. This figure shows a body-temperature curve (green line), laboratory values including troponin T level (blue lines), high-sensitivity C-reactive protein (red bars) and erythrocyte sedimentation rate (blue bars) and methylprednisolone administered during hospitalization (horizontal thick lines). Major examinations during the course of the patient’s illness are indicated by arrows. hs-CRP, high-sensitivity C-reactive protein; ESR, erythrocyte sedimentation rate; cTNT, troponin T level; MP, methylprednisolone; LVP, left ventricular posterior; LVPW, left ventricular posterior wall; ECG, electrocardiogram.