Tolerated Re-Challenge of Immunotherapy in a Patient with ICI Associated Myocarditis: A Case Report and Literature Review

Abstract

Many different types of cancer can be treated with immunotherapy drugs called immune checkpoint inhibitors (ICIs). These drugs have altered the landscape of cancer treatment options since they function by triggering a stronger immune response to malignancy. As expected, ICIs’ modification of immune regulatory controls leads to a wide range of organ/gland-specific immune-related side effects. These adverse effects are uncommonly deadly and typically improve by discontinuing treatment or administering corticosteroid drugs. As a result of a number of factors—including a lack of specificity in the clinical presentation, the possibility of overlap with other cardiovascular and general medical illnesses, difficulties in diagnosis, and a general lack of awareness—the true incidence of ICI-associated myocarditis is likely underestimated. Currently, protocols for the surveillance, diagnosis, or treatment of this condition are unclear. Several questions remain unanswered, such as how to best screen for this rare toxin, what tests should be run on patients who are suspected of having it, how to treat myocarditis once it has developed, and who is at most risk. In this article, we provide a case study of ICI-associated myocarditis and explain its key characteristics and treatment options.

Perimyocarditis Associated with Immune Checkpoint Inhibitors: A Case Report and Review of the Literature

“…In myocarditis, ECGs can show a range of changes including: non-specific T wave changes, ST elevation myocardial infarction (STEMI), sinus tachycardia, the presence of Q waves, ventricular arrhythmias, etc. [14][15][16][17][18]. ECGs are abnormal in 89% of myocarditis cases; however, with a sensitivity nearing 47%, they are insufficient to pose a diagnosis.…”

“…Additionally, troponin has an impact on treatment due to its prognostic abilities (i.e., higher troponin is suggestive of worse outcomes) [17]. Symptomatic patients should have cardiac serum markers such as BNP and NT-proBNP measured to detect cardiac strain [15]. After stabilizing her condition (she was treated with antipyretics, fluids, and norepinephrine), the patient was admitted to the department of internal medicine for further clarification and treatment.…”

“…Additionally, troponin has an impact on treatment due to its prognostic abilities (i.e., higher troponin is suggestive of worse outcomes) [17]. Symptomatic patients should have cardiac serum markers such as BNP and NT-proBNP measured to detect cardiac strain [15]. Amongst first-line examinations, if ICI-induced myocarditis is suspected, an echocardiography is routinely performed.…”

“…Amongst first-line examinations, if ICI-induced myocarditis is suspected, an echocardiography is routinely performed. If the examination is normal, further tests such as coronary angiography or cardiac stress tests can be performed if the threat of adverse cardiac events remains high [14,15].…”

“…MRI waitlists and access prevent the routine use of this imagery tool regardless of a high suspicion of myocarditis. It is essential to note that negative results in MRIs, ECG, or echocardiography do not definitively reject the possibility of myocarditis [14][15][16][17].…”