Plasma exchange plus glucocorticoids in the treatment of immune checkpoint inhibitor-induced myocarditis: A case series and review

Abstract

Immune checkpoint inhibitors (ICIs), including antiprogrammed cell-death (PD)-1/anti-PD-ligand (PDL-1) monoclonal antibodies, are effective at improving the prognosis of patients with cancer. Among immune-related adverse events, myocarditis associated with anti-PD-1/anti-PD-L1 antibodies is rare but lacks effective treatment and mortality is very high. In this study, the authors extracted data from the previous 8 years from electronic medical records housed in the hospital information system to identify patients hospitalized with myocarditis putatively caused by anti-PD-1/anti-PD-L1 tumor therapy. Clinical data from these patients are reported. Four patients who developed myocarditis after undergoing treatment with anti-PD-1/anti-PD-L1 antibodies for malignant tumors, all of whom responded favorably to therapy consisting of plasma exchange and glucocorticoids for myocarditis, and all patients improved and were discharged from hospital. Plasma exchange plus systemic glucocorticoids may be effective for treating anti-PD-1/anti-PD-L1 antibody-induced myocarditis in patients with cancer.

Keywords: glucocorticoids; immune checkpoint inhibitors; myocarditis; plasma exchange.

Figure 1

(A‐E) Changes in blood levels of lactate dehydrogenase (LDH), creatine kinase (CK), creatine kinase isoenzyme (CK‐MB), ultrasensitive troponin 1 (aTnI_T1) and myoglobin (MYO) at treatment time points in four patients. Treatment consisted of synthetic therapy based on plasma exchange in cases 1–3, and synthetic therapy based on glucocorticoids in case 4.

Figure 2

Pathology sample of muscle tissue biopsy from case 3, demonstrating partial cellular detachment and distortion, as well as perimysial lymphocytic infiltration.

Figure 3

Pathology specimen of deltoid muscle biopsy from case 4, which exhibits focal muscle fiber atrophy with interstitial lymphocytic infiltration.