Treatment strategy for myocarditis in patients using immune checkpoint inhibitors or combined anti-vascular endothelial growth factor therapy by clinical severity

Immune checkpoint inhibitor-induced myocarditis with myasthenia gravis overlap syndrome: A case report and literature review

RATIONALE

The therapeutic value of immune checkpoint inhibitors (ICIs) in a variety of tumors has been found and recognized, and although ICIs have improved the prognosis of many patients with advanced tumors, these drugs sometimes cause immune-related adverse events (irAEs).

PATIENT CONCERNS

We report a 67-year-old woman with advanced rectal endocrine tumor. Ten days after receiving two cycles of treatment with camrelizumab combined with http://www.baidu.com/link?url=shAWG4LYTwwBcZAEb6pLb6DkDndJR2tUgOfFiWAkOf0hS-_sj2jjSLBwYaxSiHY3r6yPj31Lp2DCP-7q3w7ho5HIV46V4fbIShFyUY7Cbka sorafenib, the patient suddenly suffered from chest tightness, shortness of breath and progressive aggravation of limb weakness, the high-sensitivity cardiac troponin T (hs-cTnT) was elevated to 3015pg/mL and N-terminal pro-B-type natriuretic peptide (NT-proBNP) up to 5671pg/mL, and creatine kinase (CK) was 1419U/L.

DIAGNOSIS AND INTERVENTIONS

The patient was diagnosed as immune checkpoint inhibitor-induced myocarditis with myasthenia gravis overlap syndrome. The patient was transferred to the intensive care unit (ICU) in time and given oxygen inhalation, glucocorticoids, immunoglobulin and anticholinesterase drugs, and other related treatments.

OUTCOMES

After 2 weeks, the symptoms of myasthenia gravis (MG) were relieved, and the level of myocardial injury markers decreased significantly, but it was still at a high level. The patient's family refused further treatment, and the patient died soon after.

LESSONS

In this paper, Through the report and follow-up analysis of this case, this paper recognizes that the early correct understanding and evaluation of this fulminant and fatal irAEs and the reasonable treatment of patients are very important for the prognosis of patients.

Intrinsic Differences in Immune Checkpoint Inhibitor-Induced Myocarditis: A Retrospective Analysis of Real World Data

Immune-related myocarditis is a severe and even life-threatening immune-related adverse event (irAE) which may also be underestimated due to the challenge in diagnosis. The inherent difference between individuals with immune-associated myocarditis has received little attention. Our study aimed to identify which baseline characteristics could contribute to distinguishing mild from severe ICI myocarditis. A retrospective analysis was conducted between March 2019 and June 2020 in West China Hospital, and 18 patients with immune-related myocarditis were studied. Patients were classified as having mild (n = 12) or severe myocarditis (n = 6), according to the clinical manifestations and hemodynamic complications. Factors associated with severe myocarditis were identified by comparing covariates derived from medical records in various groups. In this retrospective analysis, the median age of the 18 patients was 60 years old. Most myocarditis cases occur early and approximately after the first or second ICI infusion. The severity of myocarditis may be correlated with lactate dehydrogenase (LDH) (p = 0.04) and troponin levels (p = 0.0057). The relationship between troponin and myocarditis was further confirmed in another cohort, which included 30 patients. In addition, patients are more likely to develop multi-irAEs, and myositis was the most common second irAE. Those who experience multi-irAEs usually had significantly higher LDH (p = 0.02) and myoglobin levels (p = 0.02) than those who did not experience them. All patients were treated with steroids timely, and the mortality rate was 5.6% in our study. In this study, we explored risk factors for severe myocarditis and emphasized the importance of a multidisciplinary team in assisting diagnosis and treatment options. It is critical to initiate corticosteroid therapy, regardless of the severity of the myocarditis.