Abstract
Immune checkpoint inhibitor (ICI)-associated myocarditis is a rare but potentially fatal complication associated with development of other immune-related adverse events (irAEs). Troponin levels, ECG, echocardiography, and cardiac MR can assist with the diagnosis of this rare albeit serious adverse effect related to immunotherapy. In this case report, we present the clinical and radiological features of myocarditis in three patients presenting with acute symptoms while receiving therapy with ICIs. Blood troponin and ECG were abnormal in all three myocarditis cases. Initial echocardiography was abnormal in two patients with reduced left ventricular ejection fraction (LVEF). The third patient demonstrated an initially normal LVEF with subsequent transient decrease in LVEF on follow-up echocardiogram. Cardiac MR was abnormal in three cases with areas of mid-myocardial/epicardial delayed enhancement. All patients experienced additional irAEs. One patient died shortly after myocarditis diagnosis, one was made comfort care due to poor clinical status, and one improved with steroid treatment.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Mahmood SS, Fradley MG, Cohen JV, Nohria A, Reynolds KL, Heinzerling LM, Sullivan RJ, Damrongwatanasuk R, Chen CL, Gupta D, Kirchberger MC, Awadalla M, Hassan MZO, Moslehi JJ, Shah SP, Ganatra S, Thavendiranathan P, Lawrence DP, Groarke JD, Neilan TG (2018) Myocarditis in patients treated with immune checkpoint inhibitors. J Am Coll Cardiol 71(16):1755–1764 Available from: http://www.sciencedirect.com/science/article/pii/S0735109718333680
Wolchok JD, Chiarion-Sileni V, Gonzalez R, Rutkowski P, Grob J-J, Cowey CL et al (2017) Overall survival with combined nivolumab and ipilimumab in advanced melanoma. N Engl J Med 377(14):1345–1356. Available from:. https://doi.org/10.1056/NEJMoa1709684
Awadalla M, Golden DLA, Mahmood SS, Alvi RM, Mercaldo ND, Hassan MZO, Banerji D, Rokicki A, Mulligan C, Murphy SPT, Jones-O'Connor M, Cohen JV, Heinzerling LM, Armanious M, Sullivan RJ, Damrongwatanasuk R, Chen CL, Gupta D, Kirchberger MC, Moslehi JJ, Shah SP, Ganatra S, Thavendiranathan P, Rizvi MA, Sahni G, Lyon AR, Tocchetti CG, Mercurio V, Thuny F, Ederhy S, Mahmoudi M, Lawrence DP, Groarke JD, Nohria A, Fradley MG, Reynolds KL, Neilan TG (2019) Influenza vaccination and myocarditis among patients receiving immune checkpoint inhibitors. J Immunother Cancer 7(1):53
Johnson DB, Balko JM, Compton ML, Chalkias S, Gorham J, Xu Y et al (2016) Fulminant myocarditis with combination immune checkpoint blockade. N Engl J Med 375(18):1749–1755 Available from: https://pubmed.ncbi.nlm.nih.gov/27806233
Zimmer L, Goldinger SM, Hofmann L, Loquai C, Ugurel S, Thomas I et al (2016) Neurological, respiratory, musculoskeletal, cardiac and ocular side-effects of anti-PD-1 therapy. Eur J Cancer 60:210–225
Caforio ALP, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix SB et al (2013) Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J 34(33):2636–2648 2648a-2648d
Pollack MH, Betof A, Dearden H, Rapazzo K, Valentine I, Brohl AS et al (2018) Safety of resuming anti-PD-1 in patients with immune-related adverse events (irAEs) during combined anti-CTLA-4 and anti-PD1 in metastatic melanoma. Ann Oncol 29(1):250–255
Friedrich MG, Sechtem U, Schulz-Menger J, Holmvang G, Alakija P, Cooper LT et al (2009) Cardiovascular magnetic resonance in myocarditis: a JACC white paper. J Am Coll Cardiol 53(17):1475–1487 Available from: http://www.onlinejacc.org/content/53/17/1475
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
IRB statement
The institutional review board approved the study.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Ansari-Gilani, K., Tirumani, S.H., Smith, D.A. et al. Myocarditis associated with immune checkpoint inhibitor therapy: a case report of three patients. Emerg Radiol 27, 455–460 (2020). https://doi.org/10.1007/s10140-020-01765-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10140-020-01765-6