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. 2024 Jul 30;11(8):004729.
doi: 10.12890/2024_004729. eCollection 2024.

Durvalumab-Induced Triple-M Syndrome

Femi Williams Adeoye  1 , Nida Jaffar  2 , Sanggeeta Surandran  3 , Gulshad Begum  1   4 , Mohammad Rafiqul Islam  1   4
Affiliations

Durvalumab-Induced Triple-M Syndrome

Femi Williams Adeoye et al. Eur J Case Rep Intern Med. .

Abstract

Background: While the use of immunotherapy has revolutionised the treatment of various cancers, it is often associated with a myriad of immune-related adverse effects.

Case presentation: In this article, we report a rare case of durvalumab-induced triple-M syndrome in a 69-year-old woman with stage III lung adenocarcinoma. She was admitted with profound generalised muscle weakness, myalgia, and exertional breathlessness, about a week into her second cycle of durvalumab, an immune checkpoint inhibitor. She had clinicopathological features of myositis, myasthenia and myocarditis with acute onset symptomatic tri-fascicular block on electrocardiogram, requiring urgent cardiology intervention. Durvalumab was discontinued and she was treated with a combination of high-dose steroids and intravenous immunoglobulin after which she had clinical and biochemical improvement, albeit with residual muscle weakness.

Conclusion: Myocarditis-myositis-myasthenia complex is a rare side effect of immunotherapy which has been reported in other immune checkpoint inhibitors, but less so with durvalumab. We report this clinical case to raise awareness of this rare and potentially life-threatening adverse effect of this agent.

Learning points: Triple-M syndrome is a rare immune-related adverse effect, which has been noted in other immune checkpoint inhibitors, but less so with durvalumab specifically.Immunotherapy-induced myositis, myocarditis and myasthenia can occur in isolation or, rarely, in association as a syndrome.This case demonstrates the potentially life-threatening nature of this entity, the need for early recognition, and multi-specialist teamwork to ensure good outcome.

Keywords: Durvalumab; myastheniam; myocarditis; myositis; triple-M syndrome.

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Conflict of interest statement

Conflicts of Interests: Dr. Islam reports receiving honoraria from AstraZeneca, Servier, Pfizer and BMS. All remaining authors have declared no conflicts of interest.

Figures

Figure 1
Figure 1
Computed tomography scans before (August) and after chemoradiotherapy (December).
Figure 2
Figure 2
Whole spine magnetic resonance imaging showing paraspinal muscle oedematous changes on STIR sagittal sequence.
Figure 3
Figure 3
Electrocardiogram showing tri-fascicular block.
Figure 4
Figure 4
Serum creatinine kinase and troponin-T levels over time.
See this image and copyright information in PMC

References

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    1. Nosaki Y, Odate M, Takenaka H, Yokoi T, Iwai K. Development of myasthenia gravis: 4 years after durvalumab-induced myositis. Neurol Clin Neurosci. 2024;00:1–3.

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