Acute Myocarditis and Myositis Associated With Nivolumab Therapy

Abstract

SESSION TITLE: Student/Resident Case Report Poster - Cardiovascular Disease I SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Nivolumab a monoclonal antibody which selectively inhibits programmed cell death-1(PD-1) receptor is FDA approved for the treatment of solid cancers.1 We present a case of a 79 year old male with history of metastatic non small cell lung cancer (NSCLC) on nivolumab who presented with muscle pain, weakness and dyspnea. His presentation was consistent with nivolumab induced auto-immune myositis and myocarditis. CASE PRESENTATION: A 79 year old male presents with complaints of acute onset back pain and generalized weakness causing gait instability for 2 weeks and dyspnea for 3 days. He was diagnosed with metastatic adenocarcinoma of the lung and on treatment with nivolumab, last dose was 1 week before presentation. On presentation he was hypotensive (80/45mmHg), HR was 76 beats/min irregular rhythm. On exam S3 gallop was present and lungs were clear. There was evidence of neck flexor weakness and symmetric pure motor proximal hip flexor weakness. Hemoglobin of 10.6 g/dl, AST:1083 IU/ml, ALT:497 IU/ml. Creatine kinase 14014 U/L and aldolase of 71 U/L. Auto immune work up was negative. MRI of the proximal leg muscles showed diffuse edema in the quadriceps, adductors and gluteus muscles. Troponin T peaked at 3.66 ng/ml, and pro BNP was elevated at 9532 pg/ml. Patient developed worsening ventricular arrhythmias. His LV function was markedly reduced (LVEF15%). He was started on inotropes and amiodarone. Myocardial and muscle biopsies were planned but patient refused both the procedures.He was started on amiodarone and lidocaine for frequent multifocal ventricular tachyarrhythmias. Supportive inotropic therapy was used. After the MRI results corticosteroid therapy was initiated. On clinical examination mild improvement in muscle weakness was noted. DISCUSSION: Cancer immunotherapy is a double edged sword. Monoclonal antibodies against T cells enhance the immune response not only to cancer cells but also to normal host tissue1. The presentation of patients who present with adverse effects of these agents often mimics autoimmune diseases.In our patient the differential diagnosis of polymyositis was entertained. However the recent administration of nivolumab and negative muscle antibodies made nivolumab the likely culprit. Myositis and myocarditis have been separately reported as adverse effects of PD1 therapy.2,3 CONCLUSIONS: Immune related adverse effects of monoclonal antibodies must be identified early in the clinical course as discontinuation of the offending agent may hasten recovery. Reference #1: Brahmer JR, Tykodi SS, et al. Safety and activity of anti-PD-L1 antibody in patients with advanced cancer. N Engl J Med. 2012;366:2455-65. Reference #2: Läubli H, Balmelli C, et al. Acute heart failure due to autoimmune myocarditis under pembrolizumab treatment for metastatic melanoma. J Immunother Cancer. 2015 Apr 21;3:11. Reference #3: Yoshioka M, Kambe N, et al. Case of respiratory discomfort due to myositis after administration of nivolumab. J Dermatol. 2015 Oct;42(10):1008-9. DISCLOSURE: The following authors have nothing to disclose: Anita Mehta, Nayan Desai, Fredric Ginsberg No Product/Research Disclosure Information