Lenalidomide-Induced Myocarditis, Rare But Possibly Fatal Toxicity of a Commonly Used Immunotherapy

Jacob, Robin; Palaskas, Nicolas; Lopez‐Mattei, Juan; Marmagkiolis, Konstantinos; Buja, L. Maximilian; Deswal, Anita; Iliescu, Cezar

doi:10.1016/j.jaccas.2020.07.033

Cited by 7 publications

(9 citation statements)

References 9 publications

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“…Lenalidomide-induced myocarditis has been described in four case reports so far. 1 , 4 , 7 , 8 Interestingly, all patients were women and presented within 30 days after treatment initiation. To our knowledge, our case is the first patient presenting with hypersensitivity syndrome but without classical signs and symptoms of cardiac disease (no thoracic pain, no dyspnoea, and no signs of cardiac decompensation).…”

Section: Discussionmentioning

confidence: 99%

“…In their paper published in 2020, Jacob et al . 7 already recommend routine cardiac screening (cardiac enzymes, cardiac MRI, coronary angiography, and endomyocardial biopsy) when patients present with eosinophilia, skin reactions, or acute onset of auto-immune illness (e.g. colitis or thyroiditis) in the context of treatment with lenalidomide ( Figure 5 ).…”

Section: Discussionmentioning

confidence: 99%

“… Adapted algorithm from Jacob et al . 7 for diagnosis and management of suspected lenalidomide myocarditis. Based on our literature search and own experience, we would suggest to add transthoracic echocardiography with strain imaging to the diagnostic work up.…”

Section: Discussionmentioning

confidence: 99%

“…Surprisingly, pathology results showed no significant abnormalities according to Dallas Criteria in our patient, while other cases have reported lymphocytic/eosinophilic infiltration of the myocardium. 1 , 4 , 7 In hindsight, this is most probably ascribable to sampling error as the biopsy was taken on the right side of the heart, while the typical myocarditis features were most pronounced on the anterior wall. Therefore, in order to reduce the risk of sampling errors, imaging-guided endomyocardial biopsy should be considered when feasible, as both diffuse and localized myocarditis have been described.…”

Section: Discussionmentioning

confidence: 99%

“… 6 Lenalidomide and bortezomib are both know to be radiosensitizers, and myocarditis has been described after the use of lenalidomide. 1 , 4 , 7 , 8 …”

Section: Introductionmentioning

confidence: 99%

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Combined lenalidomide/bortezomib for multiple myeloma complicated by fulminant myocarditis: a rare case report of widely used chemotherapy

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Meekers

Vandenberghe

et al. 2022

European Heart Journal - Case Reports

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Background Drug-induced myocarditis is a rare complication of certain cancer treatments, characterized by the development of myocardial inflammation shortly after initiation of treatment, potentially leading to heart failure and/or malignant arrhythmias. The development of eosinophilic myocarditis after administration of lenalidomide has been described and bortezomib has been associated with the development of cardiomyopathies and atherosclerosis. Case Summary A 69-year-old woman, recently diagnosed with multiple myeloma underwent local radiotherapy for a pathological fracture of the fourth lumbar vertebra and was treated with bortezomib-lenalidomide-dexamethasone. Within 19 days after therapy initiation, she presented with gastrointestinal symptoms, an erythematous pruritic rash and general fatigue. Surprisingly, routine electrocardiogram showed upwardly concave ST-elevation in I and aVL and ST-depressions in II, III and aVF. Troponin levels were markedly elevated to 5470 ng/L. Complete blood count revealed eosinophilia. Based on further cardiac work-up, including echocardiography, coronary angiography and cardiac magnetic resonance imaging showing positive T2 imaging and patchy subepicardial late gadolinium enhancement, she was diagnosed with hypersensitivity myocarditis. Additional endomyocardial heart biopsy did not reveal any abnormalities, probably due to sampling error. After discontinuation of chemotherapy and prompt treatment with high doses of corticosteroids, the patient recovered. Conclusion Diagnosis of drug-induced myocarditis can be challenging and even long known widely used (chemo)therapy should be considered a potential trigger. Early diagnosis and treatment are crucial, warranting alertness for suggestive symptoms. Cardiac biomarkers, electrocardiogram monitoring and cardiac magnetic resonance imaging are key to confirm the diagnosis. In patients with preserved left ventricular systolic function, two-dimensional speckle tracking echocardiography can provide additional diagnostic information. Every patient presenting with eosinophilia and/or acute onset of auto-immune symptoms after initiation of therapy with lenalidomide/bortezomib deserves prompt cardiac screening. The gold standard remains an endomyocardial biopsy, although sampling error may occur.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

“… 6 Lenalidomide and bortezomib are both know to be radiosensitizers, and myocarditis has been described after the use of lenalidomide. 1 , 4 , 7 , 8 …”

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Combined lenalidomide/bortezomib for multiple myeloma complicated by fulminant myocarditis: a rare case report of widely used chemotherapy

Verbesselt

Meekers

Vandenberghe

et al. 2022

European Heart Journal - Case Reports

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Lenalidomide

2020

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Cardiac toxicities in multiple myeloma: an updated and a deeper look into the effect of different medications and novel therapies

et al. 2023

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With the continuous improvement in survival of cancer patients, including those with multiple myeloma, related to the novel treatment agents and therapeutic approaches, the probability for patients to develop cardiovascular disease has significantly increased, especially in elderly patients and those with additional risk factors. Multiple myeloma is indeed a disease of the elderly population and so these patients are, solely by age, at an increased risk of cardiovascular disease. Risk factors for these events can be patient-, disease- and/or therapy-related, and they have been shown to adversely impact survival. Cardiovascular events affect around 7.5% of patients with multiple myeloma and the risk for different toxicities has considerably varied across trials depending on patients’ characteristics and treatment utilized. High grade cardiac toxicity has been reported with immunomodulatory drugs (odds ratio [OR] around 2), proteasome inhibitors (OR 1.67–2.68 depending on the specific agent, and generally higher with carfilzomib), as well as other agents. Cardiac arrhythmias have also been reported with various therapies and drug interaction plays a significant role in that setting. Comprehensive cardiac evaluation before, during and after various anti-myeloma therapy is recommended and the incorporation of surveillance strategies allows early detection and management resulting in improved outcomes of these patients. Multidisciplinary interaction including hematologists and cardio-oncologists is critical for optimal patient care.

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Lenalidomide-Induced Myocarditis, Rare But Possibly Fatal Toxicity of a Commonly Used Immunotherapy

Cited by 7 publications

References 9 publications

Combined lenalidomide/bortezomib for multiple myeloma complicated by fulminant myocarditis: a rare case report of widely used chemotherapy

Combined lenalidomide/bortezomib for multiple myeloma complicated by fulminant myocarditis: a rare case report of widely used chemotherapy

Lenalidomide

Cardiac toxicities in multiple myeloma: an updated and a deeper look into the effect of different medications and novel therapies

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