A case of lymphocytic myocarditis in a patient treated with an immune checkpoint inhibitor, a recent class of chemotherapy agents
Chemotherapy-associated cardiotoxicity is a common adverse event. Immune checkpoint inhibitors (ICI) – a new class of monoclonal antibodies – have revolutionized the management of various diseases. Their use is expected to increase in the near future and their cardiac side effects have been increasi...
| Main Authors: | , , , , , , , |
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| Format: | Article |
| Language: | English |
| Published: |
Elsevier
2022-12-01
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| Series: | Revista Portuguesa de Cardiologia |
| Subjects: | |
| Online Access: | http://www.sciencedirect.com/science/article/pii/S0870255122004590 |
| _version_ | 1811293736276066304 |
|---|---|
| author | Tatiana Duarte Cátia Costa Sara Gonçalves Luís Raposo António Ferreira Catarina Albuquerque Nuno Vau Rui Caria |
| author_facet | Tatiana Duarte Cátia Costa Sara Gonçalves Luís Raposo António Ferreira Catarina Albuquerque Nuno Vau Rui Caria |
| author_sort | Tatiana Duarte |
| collection | DOAJ |
| description | Chemotherapy-associated cardiotoxicity is a common adverse event. Immune checkpoint inhibitors (ICI) – a new class of monoclonal antibodies – have revolutionized the management of various diseases. Their use is expected to increase in the near future and their cardiac side effects have been increasingly recognized. Clinical case: We describe a case of a 67-year-old female patient with urothelial carcinoma undergoing treatment with pembrolizumab who presented to the emergency department with progressive fatigue, retrosternal pain and palpitations for three days. On admission she was diagnosed with acute heart failure (HF). The electrocardiogram revealed a right bundle branch block and ventricular bigeminy. Blood tests showed elevated troponin I, while transthoracic echocardiography revealed severe left ventricular dysfunction. Coronary angiography excluded coronary artery disease. Cardiac magnetic resonance revealed moderate left ventricular dysfunction and late gadolinium enhancement typical of myocarditis. Endomyocardial biopsy confirmed the diagnosis of lymphocytic myocarditis. In the first 48h of hospitalization, she developed transient complete AV block. Corticoid and HF therapy were initiated, leading to symptom improvement and disappearance of the rhythm disturbances. She was discharged on the 12th day, maintaining moderate LV dysfunction, which improved only mildly at a subsequent outpatient assessment. She died suddenly 35 days after discharge. Conclusion: Lymphocytic myocarditis is a serious cardiac side effect of ICI therapy. Pembrolizumab is increasingly used, so it is important to be aware of its effects, in order to perform an early diagnosis and provide adequate treatment. Corticosteroid therapy seems to be crucial in preventing disease progression and enabling ventricular remodeling. Resumo: Introdução: A cardiotoxicidade associada à quimioterapia é um evento adverso comum. Uma nova classe de anticorpos monoclonais – inibidores dos checkpoints imunes – tem revolucionado o tratamento de várias neoplasias, é expectável num futuro próximo o aumento da sua prescrição. Os efeitos colaterais cardíacos são cada vez mais reconhecidos. Caso clínico: Descrevemos o caso de uma doente de 67 anos com carcinoma urotelial sob pembrolizumab, admitida no serviço de urgência (SU) por fadiga, dor retrosternal e palpitações com três dias de evolução. No SU foi diagnosticada com insuficiência cardíaca aguda. O ECG relevou bloqueio completo de ramo direito e bigeminismo ventricular e na avaliação analítica com elevação dos biomarcadores de necrose miocárdica.O ecocardiograma transtorácico revelou disfunção ventricular esquerda grave. A coronariografia excluiu doença coronária. A ressonância cardíaca evidenciou disfunção moderada e padrão sugestivo de miocardite. A biópsia do miocárdio confirmou o diagnóstico de miocardite linfocítica. Nas primeiras 48 h de internamento apresentou períodos de bloqueio AV completo. Foi iniciada corticoterapia e terapêutica neuro-humoral, com rápida melhoria clínica e maior estabilidade elétrica. A doente teve alta ao 12.° dia, mantendo disfunção ventricular moderada. Em ambulatório, foi avaliada apresentando uma ligeira melhoria da fração de ejeção. Ao 35.° dia após alta, a doente faleceu. Conclusão: A miocardite linfocítica é um evento adverso grave associado à imunoterapia. O uso do pembrolizumab tem aumentado, é importante conhecer os seus efeitos adversos, para permitir um diagnóstico precoce e uma adequada terapêutica. A corticoterapia parece ser crucial na prevenção da progressão da doença e no remodeling ventricular. |
| first_indexed | 2024-04-13T05:05:57Z |
| format | Article |
| id | doaj.art-fdac67f0b87f4234a9715c93bcf88bb3 |
| institution | Directory Open Access Journal |
| issn | 0870-2551 |
| language | English |
| last_indexed | 2024-04-13T05:05:57Z |
| publishDate | 2022-12-01 |
| publisher | Elsevier |
| record_format | Article |
| series | Revista Portuguesa de Cardiologia |
| spelling | doaj.art-fdac67f0b87f4234a9715c93bcf88bb32022-12-22T03:01:11ZengElsevierRevista Portuguesa de Cardiologia0870-25512022-12-01411210471051A case of lymphocytic myocarditis in a patient treated with an immune checkpoint inhibitor, a recent class of chemotherapy agentsTatiana Duarte0Cátia Costa1Sara Gonçalves2Luís Raposo3António Ferreira4Catarina Albuquerque5Nuno Vau6Rui Caria7Cardiology Department, Hospital de S. Bernardo, Centro Hospitalar de Setúbal, Setúbal, Portugal; Corresponding author.Cardiology Department, Hospital de S. Bernardo, Centro Hospitalar de Setúbal, Setúbal, PortugalCardiology Department, Hospital de S. Bernardo, Centro Hospitalar de Setúbal, Setúbal, PortugalHospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, PortugalHospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, PortugalHospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, PortugalFundação Champalimaud, Lisbon, PortugalCardiology Department, Hospital de S. Bernardo, Centro Hospitalar de Setúbal, Setúbal, PortugalChemotherapy-associated cardiotoxicity is a common adverse event. Immune checkpoint inhibitors (ICI) – a new class of monoclonal antibodies – have revolutionized the management of various diseases. Their use is expected to increase in the near future and their cardiac side effects have been increasingly recognized. Clinical case: We describe a case of a 67-year-old female patient with urothelial carcinoma undergoing treatment with pembrolizumab who presented to the emergency department with progressive fatigue, retrosternal pain and palpitations for three days. On admission she was diagnosed with acute heart failure (HF). The electrocardiogram revealed a right bundle branch block and ventricular bigeminy. Blood tests showed elevated troponin I, while transthoracic echocardiography revealed severe left ventricular dysfunction. Coronary angiography excluded coronary artery disease. Cardiac magnetic resonance revealed moderate left ventricular dysfunction and late gadolinium enhancement typical of myocarditis. Endomyocardial biopsy confirmed the diagnosis of lymphocytic myocarditis. In the first 48h of hospitalization, she developed transient complete AV block. Corticoid and HF therapy were initiated, leading to symptom improvement and disappearance of the rhythm disturbances. She was discharged on the 12th day, maintaining moderate LV dysfunction, which improved only mildly at a subsequent outpatient assessment. She died suddenly 35 days after discharge. Conclusion: Lymphocytic myocarditis is a serious cardiac side effect of ICI therapy. Pembrolizumab is increasingly used, so it is important to be aware of its effects, in order to perform an early diagnosis and provide adequate treatment. Corticosteroid therapy seems to be crucial in preventing disease progression and enabling ventricular remodeling. Resumo: Introdução: A cardiotoxicidade associada à quimioterapia é um evento adverso comum. Uma nova classe de anticorpos monoclonais – inibidores dos checkpoints imunes – tem revolucionado o tratamento de várias neoplasias, é expectável num futuro próximo o aumento da sua prescrição. Os efeitos colaterais cardíacos são cada vez mais reconhecidos. Caso clínico: Descrevemos o caso de uma doente de 67 anos com carcinoma urotelial sob pembrolizumab, admitida no serviço de urgência (SU) por fadiga, dor retrosternal e palpitações com três dias de evolução. No SU foi diagnosticada com insuficiência cardíaca aguda. O ECG relevou bloqueio completo de ramo direito e bigeminismo ventricular e na avaliação analítica com elevação dos biomarcadores de necrose miocárdica.O ecocardiograma transtorácico revelou disfunção ventricular esquerda grave. A coronariografia excluiu doença coronária. A ressonância cardíaca evidenciou disfunção moderada e padrão sugestivo de miocardite. A biópsia do miocárdio confirmou o diagnóstico de miocardite linfocítica. Nas primeiras 48 h de internamento apresentou períodos de bloqueio AV completo. Foi iniciada corticoterapia e terapêutica neuro-humoral, com rápida melhoria clínica e maior estabilidade elétrica. A doente teve alta ao 12.° dia, mantendo disfunção ventricular moderada. Em ambulatório, foi avaliada apresentando uma ligeira melhoria da fração de ejeção. Ao 35.° dia após alta, a doente faleceu. Conclusão: A miocardite linfocítica é um evento adverso grave associado à imunoterapia. O uso do pembrolizumab tem aumentado, é importante conhecer os seus efeitos adversos, para permitir um diagnóstico precoce e uma adequada terapêutica. A corticoterapia parece ser crucial na prevenção da progressão da doença e no remodeling ventricular.http://www.sciencedirect.com/science/article/pii/S0870255122004590CardiotoxicidadeInibidores dos checkpoint imunesPembrolizumabMiocardite linfocítica |
| spellingShingle | Tatiana Duarte Cátia Costa Sara Gonçalves Luís Raposo António Ferreira Catarina Albuquerque Nuno Vau Rui Caria A case of lymphocytic myocarditis in a patient treated with an immune checkpoint inhibitor, a recent class of chemotherapy agents Revista Portuguesa de Cardiologia Cardiotoxicidade Inibidores dos checkpoint imunes Pembrolizumab Miocardite linfocítica |
| title | A case of lymphocytic myocarditis in a patient treated with an immune checkpoint inhibitor, a recent class of chemotherapy agents |
| title_full | A case of lymphocytic myocarditis in a patient treated with an immune checkpoint inhibitor, a recent class of chemotherapy agents |
| title_fullStr | A case of lymphocytic myocarditis in a patient treated with an immune checkpoint inhibitor, a recent class of chemotherapy agents |
| title_full_unstemmed | A case of lymphocytic myocarditis in a patient treated with an immune checkpoint inhibitor, a recent class of chemotherapy agents |
| title_short | A case of lymphocytic myocarditis in a patient treated with an immune checkpoint inhibitor, a recent class of chemotherapy agents |
| title_sort | case of lymphocytic myocarditis in a patient treated with an immune checkpoint inhibitor a recent class of chemotherapy agents |
| topic | Cardiotoxicidade Inibidores dos checkpoint imunes Pembrolizumab Miocardite linfocítica |
| url | http://www.sciencedirect.com/science/article/pii/S0870255122004590 |
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