Myasthenia gravis induced or exacerbated by immune checkpoint inhibitors: a rising concern

Abstract

Immune checkpoint inhibitors can cause immune side effects, with myasthenia gravis (MG) being relatively rare. With this review, we present 66-year-old man with melanoma treated with pembrolizumab who developed MG. With immuno-oncology (IO) single agent usage, 42 cases reported new-onset MG and 9 cases reported exacerbation of pre-existing MG. Among the patients who had new-onset MG after administration of programmed cell death protein 1 (PD-1) inhibitors, 14 patients (38.8%) developed severe respiratory failure and required intubation and 10 patients (27.02%) died. Among the patients with exacerbation of pre-existing MG after receiving PD-1 inhibitors, 1 patient (11.1%) required intubation, and no death was reported. Combination IO therapy-induced MG was reported in seven cases, with at least two cases complicated by respiratory failure and one death. Our observations suggest a possible difference in the severity of the disease and outcome among different IO therapy options.

Spontaneous development of myasthenia gravis and myositis following treatment with pembrolizumab: a case report

“…It's important to note that the presentation of de-novo MG has a more variable presentation than the standard MG. Recent literature has shown that de-novo MG correlates poorly with radiographic findings classically suggestive of MG such as thymoma or thymic hyperplasia [7,9]. Other studies have suggested that some phenotypes might even be subclinical in nature; thus, in the setting of acute illness, some subtypes of de-novo MG may be missed.…”

Bullous pemphigoid exacerbated by nivolumab and temporally rescued with therapeutic plasma exchange

“…Dear Editor, Immune checkpoint inhibitors (ICIs) are regarded as a therapeutic option for progressive malignancy even if autoimmune disorders such as myasthenia gravis (MG) are complicated in real-world settings. 1 Up to now, ICI-exacerbated preexisting bullous pemphigoid (BP) has been rarely reported unlike ICI-induced BP. 2 Therapeutic plasma exchange (TPE) is not mentioned for cutaneous immunerelated adverse events (IrAEs) on the American Society of Clinical Oncology clinical practice guidelines.…”