Immune checkpoint inhibitor-mediated myasthenia gravis with focal subclinical myocarditis progressing to symptomatic cardiac disease

BMJ Case Rep. 2020 May 13;13(5):e232920. doi: 10.1136/bcr-2019-232920.

Abstract

The advent of immune checkpoint inhibitors (ICIs) for cancer therapy has heralded increasing frequency of immune-related adverse events including endocrinopathies, hepatitis, colitis and rarely myocarditis and myasthenia gravis (MG). The heterogeneity in clinical presentations regardless of organ-specific involvement can lead to delayed recognition and management of these events and adverse health outcomes. We describe a case of ICI-induced subclinical focal myocarditis that was recognised and treated in the broader context of MG. It is essential that patients with ICI-induced MG should be screened and monitored for myocarditis, a potentially fatal complication.

Keywords: heart failure; malignant disease and immunosuppression; radiology (diagnostics); skin cancer; unwanted effects / adverse reactions.

Publication types

  • Case Reports

MeSH terms

  • Brain Neoplasms / drug therapy
  • Brain Neoplasms / secondary
  • Diagnosis, Differential
  • Heart Failure / chemically induced*
  • Heart Failure / diagnostic imaging
  • Heart Failure / drug therapy
  • Humans
  • Immune Checkpoint Inhibitors / administration & dosage
  • Immune Checkpoint Inhibitors / adverse effects*
  • Ipilimumab / administration & dosage
  • Ipilimumab / adverse effects
  • Lung Neoplasms / drug therapy
  • Lung Neoplasms / secondary
  • Male
  • Melanoma / drug therapy
  • Melanoma / pathology
  • Middle Aged
  • Myasthenia Gravis / chemically induced*
  • Myasthenia Gravis / diagnostic imaging
  • Myasthenia Gravis / drug therapy
  • Myocarditis / chemically induced*
  • Myocarditis / diagnostic imaging
  • Myocarditis / drug therapy
  • Nivolumab / administration & dosage
  • Nivolumab / adverse effects

Substances

  • Immune Checkpoint Inhibitors
  • Ipilimumab
  • Nivolumab