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Case Reports
. 2021 Feb 15;60(4):569-573.
doi: 10.2169/internalmedicine.5412-20. Epub 2020 Oct 7.

Asymptomatic Immune Checkpoint Inhibitor-associated Myocarditis

Junya Tanabe  1 , Nobuhide Watanabe  1 , Akihiro Endo  1 , Taichi Nagami  2 , Satoshi Inagaki  3 , Kazuaki Tanabe  1
Affiliations
Case Reports

Asymptomatic Immune Checkpoint Inhibitor-associated Myocarditis

Junya Tanabe et al. Intern Med. .

Abstract

We herein report the case of a 75-year-old man with asymptomatic immune checkpoint inhibitor (ICI)-associated myocarditis diagnosed on the basis of elevated levels of creatine kinase (CK), CK-myocardial band and troponin I (TNI). He was suspected of being complicated with myasthenia gravis (MG). High-dose prednisolone (PSL) is associated with a risk of MG exacerbation; therefore, PSL therapy was gradually increased from 5 mg/day to 20 mg/day, which resulted in the normalization of the TNI level, and no PSL-related side effects occurred. MG easily complicates myocarditis as an immune-related adverse event; thus, the treatment plan should be carefully considered.

Keywords: immune checkpoint inhibitor; immune-related adverse event; myasthenia gravis; myocarditis; prednisolone.

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Conflict of interest statement

The authors state that they have no Conflict of Interest (COI).

Figures

Figure 1.
Figure 1.
Computed tomography. The patient was diagnosed with right renal cell carcinoma with liver (A, arrows), pericardial (B, arrow), and cervical spine (C, arrow) metastases (Day 0). Both the primary and metastatic sites of the tumor showed a significant reduction (D, E, F) (Day 58).
Figure 2.
Figure 2.
Twelve-lead electrocardiography revealed a normal sinus rhythm and left anterior hemiblock (A). Chest radiography revealed a cardiothoracic ratio of 51%, no pulmonary congestion, and no pleural effusion (B).
Figure 3.
Figure 3.
On admission (Day 53), the LV global longitudinal strain was -14.4% (A). Three months after discharge (Day 170), the LV global longitudinal strain improved to -19.5% (B).
Figure 4.
Figure 4.
Coronary angiography (A: right coronary artery, B: left coronary artery) reveals no evidence of acute coronary syndrome.
Figure 5.
Figure 5.
Cardiac magnetic resonance imaging. A global increase in the T2 signal intensity can be observed (A), but the late gadolinium enhancement (LGE) imaging finding was normal (B), indicating the presence of myocardial edema.
Figure 6.
Figure 6.
Clinical course. Prednisolone (PSL) administration was started at 5 mg/day on Day 61. CK peaked on Day 64, and TNI peaked on Day 67 when the dose was gradually increased by 5 mg every 3 days. On Day 73, the PSL dose was increased to 20 mg/day, and the patient's eosinophil count and TNI levels were normalized on Day 102. CK: creatine kinase (normal range: 59-248 U/L), TNI: troponin I (normal range: <0.04 ng/mL), Eos: eosinophil count (normal range: <500/μL)
See this image and copyright information in PMC

References

    1. Postow MA, Sidlow R, Hellmann MD. Immune-related adverse events associated with immune checkpoint blockade. N Engl J Med 378: 158-168, 2018. - PubMed
    1. Salem JE, Manouchehri A, Moey M, et al. . Cardiovascular toxicities associated with immune checkpoint inhibitors: an observational, retrospective, pharmacovigilance study. Lancet Oncol 19: 1579-1589, 2018. - PMC - PubMed
    1. Love VA, Grabie N, Duramad P, et al. . CTLA-4 ablation and interleukin-12 driven differentiation synergistically augment cardiac pathogenicity of cytotoxic T lymphocytes. Circ Res 101: 248-257, 2007. - PubMed
    1. Bonaca MP, Olenchock BA, Salem JE, et al. . Myocarditis in the setting of cancer therapeutics. Proposed case definitions for emerging clinical syndromes in cardio-oncology. Circulation 140: 80-91, 2019. - PMC - PubMed
    1. Ferreira VM, Schulz-Menger J, Holmvang G, et al. . Cardiovascular magnetic resonance in nonischemic myocardial inflammation. Expert recommendations. J Am Coll Cardiol 72: 3158-3176, 2018. - PubMed

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