Abstract 12587: Cardiac Tamponade and Pericardial Effusion in a Patient With Stage 3 Malignant Melanoma Treated With Pembrolizumab

Abstract

Introduction: The introduction of immunotherapy has revolutionized the treatment of cancer, with improved clinical outcomes. One of such agents include Pembrolizumab a humanized antibody which acts as an immune check point inhibitor by binding to Programmed cell death Protein 1 receptors. One principal setback is its autoimmune-dysfunctional side effect. Case Presentation: A 74-year-old male with BRAF-negative malignant melanoma status post resection, with recurrent neoplasm involving lymph nodes of the base of the left neck presented to the emergency department with palpitations, diarrhea and difficulty in breathing. Symptoms began three weeks after his fourth course of adjuvant therapy. On presentation he was hemodynamically unstable with positive Kussmaul sign on examination. His heart sounds were muffled, with clear lung bases bilaterally. Results of EKG and echo are has shown below. Decision-Making: Patient was commenced on Intravenous fluid normal saline, oxygen therapy, was evaluated by cardiology and had emergency pericardiocentesis with about 250mls of fluid drained from the pericardial cavity and improvement of symptoms. Pericardial fluid analysis showed acute inflammation without malignant cells. Patient was placed on steroids and a consensus was reached to discontinue Pembrolizumab and pursue other lines of treatment as determined by the hospital tumor board. Discussion: The exact incidence of pericardial disease in cancer patients treated with Immune check inhibitors including Pembrolizumab is unknown. When effusion occurs, urgent intervention should be performed to prevent life threatening cardiac events. Treatment with steroids has shown improved outcomes and should be encouraged. Conclusion: Pericardial effusion is a fatal complication of Pembrolizumab. Though incidence remains rare, a high index of suspicion should be maintained in Patients receiving this immune check point inhibitor. The Decision to continue therapy after a cardiovascular event such as Pericardial Effusion should be individualized.