Nivolumab-induced myocarditis complicated by complete atrioventricular block in a patient with metastatic non-small cell lung cancer

Abstract

We report a case of a 74-year-old man who developed myocarditis complicated by atrioventricular (AV) block following two doses of nivolumab for the treatment of non-small cell lung cancer. A diagnosis of drug-induced acute myocarditis with complete AV block was considered on the basis of elevated troponin, new onset left ventricular (LV) systolic dysfunction, absence of acute myocardial infarction and some findings suggestive of myocarditis on cardiac magnetic resonance. The patient was commenced on glucocorticoids, perindopril and carvedilol. AV block and LV dysfunction persisted despite 2 weeks of treatment. He ultimately became hypotensive which prompted an implantation of a cardiac resynchronisation therapy pacemaker. Follow-up echocardiogram at 6 weeks showed resolution of LV systolic dysfunction. However, he continued to have AV block.

Immune checkpoint inhibitor-induced myocarditis in lung cancer patients: a case report of sintilimab-induced myocarditis and a review of the literature

“…Corticosteroid therapy is a double-edged sword which may induce new allergic reactions while treating other immune reactions (43,44). Previous case reports have shown high levels of myocardial biomarkers such as N terminal pro-hormone B-type natriuretic peptide (NT-proBNP), high sensitivity (hs)-troponin, and creatine kinase (CK) (10,18,20). In contrast, our lung cancer patient did not present with drastically altered levels of these biomarkers.…”

“…In this investigation, the clinical characteristics, diagnosis, and treatment of 20 cases of ICI-induced myocarditis in patients with lung cancer were reviewed and summarized in Table 1 (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25). We present the following article in accordance with the CARE reporting checklist (available at http://dx.doi.org/10.21037/apm-20-2449).…”

Durvalumab-associated Late-onset Myocarditis Successfully Treated with Corticosteroid Therapy

“…Several case reports and case series have documented myocarditis with concomitant ICIs (3)(4)(5). Although a case of myocarditis after tremelimumab plus durvalumab for endometrial cancer has been reported (6), to our knowledge, there are currently no detailed case reports about myocarditis following the administration of durvalumab for NSCLC aside from the one presented here.…”

“…Myocarditis induced by irAEs has not occurred frequently and is reported to account for approximately 1.14% of all irAEs (5). Several case series and case reports have described myocarditis related to ICIs, such as nivolumab, pembrolizumab, ipilimumab, tremelimumab, atezolizumab, avelumab, and durvalumab (3)(4)(5). Regarding durvalumab, there exists a case report of myocarditis occurring approximately four weeks after tremelimumab plus durvalumab treatment for endometrial cancer ( 6), but no cases of lung cancer with concomitant myocarditis associated with durvalumab have been reported.…”

Analysis of Corticosteroids in Immune Checkpoint Inhibitors (ICE) Induced Myocarditis – A Systematic Review of 352 Screened Articles

“…Those who were on combination ICI had earlier symptoms compared to patients on one ICI, 10 out of 17 patients who were on combination regimen presented with their symptoms after the first dose. [13,18,18,24,27,25,36,37] Out of 50 patients, 23 patients (46%) had elevated CK, 13 (26 %) patients had elevated CK-MB, 37 (74 %) patients had increased troponin I/T, 13 (26 %) patients had increased BNP level, 7 (14 %) patients had increased other test including AST, ALT, ANA titer, CRP, LDH, interleukin, myoglobin levels. The mean of ejection fraction was 39.56 % ± 17.72 % (13%-73%).…”