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Kitazaki Y, Yamamura O, Usui K, Ueno A, Sanada S, Sasaki H, Endo Y, Enomoto S, Ikawa M, Nakamoto Y, Hamano T. Anti-Kv1.4 Antibody-positive Nivolumab-induced Myasthenia Gravis and Myositis Presenting with Bilateral Ptosis and Demonstrating Different Pathophysiologies. Intern Med 2023; 62:3013-3020. [PMID: 37839874 PMCID: PMC10641203 DOI: 10.2169/internalmedicine.0739-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/21/2022] [Indexed: 10/17/2023] Open
Abstract
Nivolumab blocks inhibitors of T-cell activation and restores antitumor immunity but promotes T-cell activity in host tissues by blocking inhibition of the T-cell function, resulting in immune-related adverse effects. We herein report an 80-year-old man presenting with nivolumab-related myasthenia gravis with anti-muscular voltage-gated potassium channel-complex (Kv1.4) antibodies. On day 29 after nivolumab administration, he simultaneously developed rapidly progressing right ptosis and left facial paralysis. Nivolumab administration was discontinued. He subsequently presented with bulbar paralysis, dyspnea, and muscle weakness and received intravenous immunoglobulin, methylprednisolone, and plasma exchange. The severity of nivolumab-related myasthenia gravis with anti-Kv1.4 antibodies presented with diverse clinical findings.
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Affiliation(s)
- Yuki Kitazaki
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Osamu Yamamura
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
- Department of Community Medicine, Faculty of Medical Science, University of Fukui, Japan
| | - Kojiro Usui
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Asako Ueno
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
- Department of Neurology, Fukui-ken Saiseikai Hospital, Japan
| | - Sayaka Sanada
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Hirohito Sasaki
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Yoshinori Endo
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Soichi Enomoto
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Masamichi Ikawa
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
- Department of Advanced Medicine for Community Healthcare, Faculty of Medical Sciences, University of Fukui, Japan
| | - Yasunari Nakamoto
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
| | - Tadanori Hamano
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Japan
- Department of Aging and Dementia, Faculty of Medical Sciences, University of Fukui, Japan
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Wu Y, Xu Y, Xu L. Drug therapy for myocarditis induced by immune checkpoint inhibitors. Front Pharmacol 2023; 14:1161243. [PMID: 37305530 PMCID: PMC10248045 DOI: 10.3389/fphar.2023.1161243] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/05/2023] [Indexed: 06/13/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs), including cytotoxic T-lymphocyte antigen 4 (CTLA-4), programmed cell death 1 (PD-1), and its ligand 1 (PD-L1), have improved the survival in multiple types of cancers; however, ICIs may cause cardiovascular toxicity. Although rare, ICI-mediated cardiotoxicity is an extremely serious complication with a relatively high mortality. In this review, we discuss the underlying mechanism and clinical manifestations of cardiovascular toxicity induced by ICIs. According to previous studies, multiple signaling pathways are involved in myocarditis induced by ICIs. Further, we summarize the clinical trials of drugs for the treatment of ICI-associated myocarditis. Although these drugs have shown the beneficial effects of alleviating cardiac function and reducing mortality rates, their efficacy is not optimal. Finally, we discuss the therapeutic potential of some novel compounds as well as the underlying mechanisms of their action.
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Affiliation(s)
- Yihao Wu
- Department of Cardiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yizhou Xu
- Department of Cardiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Linhao Xu
- Department of Cardiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Department of Laboratory Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Seligman C, Chang YM, Luo J, Garden OA. Exploring the role of immune checkpoint inhibitors in the etiology of myasthenia gravis and Lambert-Eaton myasthenic syndrome: A systematic review. Front Neurol 2023; 13:1004810. [PMID: 36698907 PMCID: PMC9868566 DOI: 10.3389/fneur.2022.1004810] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
Background While immune checkpoint inhibitors (ICIs) have been revolutionary in the treatment of cancer, their administration has been associated with a variety of immune-related adverse events (irAEs), including myasthenia gravis (MG), and Lambert-Eaton myasthenic syndrome (LEMS). Objective To provide a comprehensive synthesis of the evidence supporting an etiological role for ICIs in MG and LEMS in patients with no prior history of autoimmune disease. Hypothesis ICIs may trigger MG and LEMS in patients with no prior susceptibility to autoimmune disease. Methods Relevant primary research on Medline was interrogated using a series of search algorithms. Search terms were constructed based on the PICOS tool endorsed by the Cochrane Collaboration, which describes population, intervention, comparison, outcomes, and study design. Papers were screened according to inclusion and exclusion criteria. Additional papers were retrieved from the reference lists of screened papers. Each paper included in the qualitative synthesis was assigned an integrated metric of evidence (IME) value, ranging from 0 to 7, based on study design, quality of data, likelihood of a causal link between the immune checkpoint inhibitor(s) and MG/LEMS, confidence of MG/LEMS diagnosis, and the number of patients treated with an ICI prior to MG/LEMS diagnosis. Results Ninety-four papers describing at least one patient treated with ICI(s) prior to the onset of MG and/or LEMS were documented. Overall evidence for a causal link between ICI administration and MG/LEMS was low, with a median IME value of 2.88 (range 2.05-6.61). Conclusions There is a paucity of evidence in support of an etiological relationship between ICIs and MG/LEMS, due largely to the lack of mechanistic studies and/or prospective clinical trials with relevant study endpoints. The current literature is dominated by case reports and retrospective cohort studies, which inherently yield only low-level evidence, supporting the need for further work in this area. A role of ICIs in the etiology of MG/LEMS remains plausible, arguing for continued vigilance for irAEs in patients treated with these drugs. We argue that there is a need for future mechanistic, high quality, large-scale studies specifically investigating the possible etiological role of ICIs in MG/LEMS.
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Affiliation(s)
- Carly Seligman
- Garden & Luo Immune Regulation Laboratory, Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Yu-Mei Chang
- Department of Comparative Biomedical Sciences, Royal Veterinary College, University of London, London, United Kingdom
| | - Jie Luo
- Garden & Luo Immune Regulation Laboratory, Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Oliver A. Garden
- Garden & Luo Immune Regulation Laboratory, Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States,Dean's Office, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, United States,*Correspondence: Oliver A. Garden ✉
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Onwuemene OA, Nnoruka CI, Patriquin CJ, Connelly-Smith LS. Therapeutic plasma exchange in the management of immune checkpoint inhibitor-associated immune-related adverse effects: A review. Transfusion 2022; 62:2370-2390. [PMID: 36134464 DOI: 10.1111/trf.17114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/31/2022] [Accepted: 08/31/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Oluwatoyosi A Onwuemene
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Chizoba I Nnoruka
- Division of Hematology/Oncology, Sibley Memorial Hospital, Sibley Memorial Hospital John Hopkins University, Washington, DC, USA
| | - Christopher J Patriquin
- Department of Medicine, Division of Medical Oncology & Hematology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Laura S Connelly-Smith
- Department of Medicine, University of Washington and Fred Hutchinson Cancer Center, Seattle, Washington, USA
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Lei Y, Zheng X, Huang Q, Li X, Qiu M, Liu M. Intrinsic Differences in Immune Checkpoint Inhibitor-Induced Myocarditis: A Retrospective Analysis of Real World Data. Front Pharmacol 2022; 13:914928. [PMID: 35865949 PMCID: PMC9294234 DOI: 10.3389/fphar.2022.914928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/06/2022] [Indexed: 12/01/2022] Open
Abstract
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.
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Su L, Liu C, Wu W, Cui Y, Wu M, Chen H. Successful Therapy for Myocarditis Concomitant With Complete Heart Block After Pembrolizumab Treatment for Head and Neck Squamous Cell Carcinoma: A Case Report With Literature Review. Front Cardiovasc Med 2022; 9:898756. [PMID: 35647073 PMCID: PMC9133913 DOI: 10.3389/fcvm.2022.898756] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 04/15/2022] [Indexed: 11/16/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy over the past decade. Despite their beneficial effects on treating numerous types of tumors, cardiotoxicity resulting from ICIs is a rare side effect but a concerning one due to its high mortality rate. We herein describe a case of an 80-year-old woman with recurrent head and neck squamous cell cancer (HNSCC), who presented with myocarditis complicated by complete atrioventricular block (CAVB) after second infusion of pembrolizumab. After quickly ruling out myocardial infarction and viral myocarditis, the strong relationship between the onset time and pembrolizumab therapy suggested that ICI-induced myocarditis was the most possible diagnosis. Though CAVB frequently presents with fulminant myocarditis in the setting of ICI-related cardiotoxicity, the patients kept a stable hemodynamic status and had normal myocardial function with just a slightly low global longitudinal strain (GLS) at−16.4%, which implied myocardial injury but was highly related to good prognosis based on the existing literature. Besides, elderly patients are vulnerable to adverse outcomes of steroid therapy, notably opportunistic infections. To balance beneficial effects and adverse effects of immune suppression, she accepted high-dose steroids without pulse methylprednisolone. Excitingly, she had a dramatic clinical and laboratory improvement, and heart block quickly returned to normal sinus rhythm. Another interesting finding was that the patient's tumor remained stable during the half-year follow-up from the termination of immunotherapy. Besides, we here firstly review previously reported cases in terms of their clinical characteristics and prognosis of ICI-induced myocarditis with CAVB, in particular the reversibility of heart block. In conclusion, ICI-induced myocarditis can be life-threatening and it therefore warrants efforts to increase awareness, facilitate early detection, and initiate prompt intervention. Importantly, CAVB secondary to ICIs-induced myocarditis may not always present with fulminant myocarditis and more than 50% of these surviving patients might recover to normal sinus rhythm. For patients with ICI-induced myocarditis with contraindication for cardiac magnetic resonance (CMR), speckle-tracking echocardiography is a reliable and sensitive alternative to CMR for detecting myocardial injury, and GLS may be an important prognostic indicator.
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Affiliation(s)
- Lina Su
- Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Chuanfen Liu
- Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Wenjie Wu
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, China
| | - Yuxia Cui
- Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Manyan Wu
- Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Hong Chen
- Department of Cardiology, Peking University People's Hospital, Beijing, China
- *Correspondence: Hong Chen
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