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Constance Thibault, Yann Vano, Gilles Soulat, Mariana Mirabel, Immune checkpoint inhibitors myocarditis: not all cases are clinically patent, European Heart Journal, Volume 39, Issue 38, 07 October 2018, Page 3553, https://doi.org/10.1093/eurheartj/ehy485
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A 52-year-old male patient with no remarkable past medical history was diagnosed with stage IV renal cell carcinoma. Initial treatment included left-sided nephrectomy, followed by a combination of immune checkpoint inhibitors (ICI) including nivolumab (programmed death 1 ICI antibody) and ipilimumab (anti-cytotoxic T-lymphocyte-associated antigen 4 antibody) every 21 days. In the light of raising concerns of double ICI, cardiovascular tests were performed before initiation of treatment with serial serum troponin measurements whilst on ICI. Pre-therapeutic echocardiogram (left ventricular ejection fraction 70% by Simpson biplane method, global longitudinal strain −21.0%), and 24-h Holter ECG monitor were normal. Ultrasensitive troponin Ic was <0.01 µg/L; serum creatinine 116 µmol/L.
The patient received the first course of combination ICI followed by high fever, rigours, and Grade I skin rash. The second course of ICI 21 days later was well tolerated. Following the third course of ICI, the patient was asymptomatic with mild troponin Ic raise of 0.61 µg/L. Twelve-lead ECG, echocardiogram and 24-h Holter ECG monitor remained unchanged. Recent viral infection was ruled out. Cardiac magnetic resonance (CMR) showed evidence of acute myocarditis (Panel). A multidisciplinary team decided switch to nivolumab alone under beta-blocker therapy with no subsequent clinical event after three cycles, and gradual decrease of troponin Ic levels to normal.
