Myasthenia Gravis Induced by Nivolumab: A Case Report

Abstract

Nivolumab is a programmed cell death receptor (PD-1) inhibitor therapy for aggressive cancers; however, it poses a risk of immune-related adverse side effects. We present a 73-year-old male with renal cell carcinoma who developed myasthenia gravis (MG) after being treated with nivolumab, proven by acetylcholine receptor antibodies. Our patient presented with symptoms of fatigue and upper and lower extremity weakness, eventually resulting in respiratory failure as a result of MG. Nivolumab is an emerging therapy for advanced cancers but poses severe immune-related adverse events. Clinicians using PD-1 inhibitors should have a high index of suspicion of autoimmune diseases so that early discontinuation and treatment can be established to limit long-term morbidity and mortality.

Immune checkpoint inhibitors in the onset of myasthenia gravis with hyperCKemia

“…We obtained data for 17 cases of ICI therapy followed by MG with hyperCKemia or anti‐striational antibody, as shown in Table . The patients in 15 cases had hyperCKemia and the patients in four of these cases complained of myalgia.…”

Neuromuscular adverse events associated with anti-PD-1 monoclonal antibodies

“…A high number of patients showed signs of cardiac involvement in the form of either elevated myocardial enzymes [11][12][13]21,22,26,32,39,46,50,60,71,72 , ECG changes 26,32,46 , abnormal echocardiography 71 , cardiac arrest 14 , or cardiac symptoms prior to death 30,41,48,71 . The coexistence of myasthenia, myopathy and myocarditis was also noted by Suzuki et al 73 .…”

“…In a Japanese population, the incidence of myasthenia gravis was 0.12% in patients treated with nivolumab 9 . Of note, other authors found evidence of concurrent myositis and/or neuropathy, which indicates that side effects following nivolumab and pembrolizumab also involve neuromuscular tissue distal and proximal from the neuromuscular junction [10][11][12][13][14][15][16] .…”

“…Eight of 14 patients with more than one NMD diagnosis reported EMG examination (one was normal, remaining seven with signs of myopathy. One patient diagnosed with myasthenia gravis and rhabdomyolysis had denervation potentials in all tested muscles14 .ENG results were reported for 5/23 patients with myasthenia gravis, of which one had indications of axonal critical illness neuropathy43 . In the neuropathy group 17/20…”