Alemtuzumab induced myocarditis and myocardial dysfunction in a patient with multiple sclerosis: A case report

Abstract

Two months after administering the first cycle of Alemtuzumab IV infusion at a dose of 12 mg\d for 5 days for MS treatment, a 28-year-old female presented with 1-day history of sudden severe chest discomfort, dyspnea, orthopnea and palpitation. On physical examination, the patient was in respiratory distress associated with tachycardia of 115/min, BP was 130\90, afebrile. Cardiac examination showed normal S1 an S2 heart sounds, with no murmurs, no JVP distention noted. However, the respiratory examination revealed fine basal lung crepitation bilaterally as well as bilateral lower edema in keeping with pulmonary edema. Neurological exam was stable. ECG showed sinus tachycardia and elevated ST segment elevation in all leads. Her echocardiogram was highly suggestive of acute myocarditis with reduced left ventricular ejection fraction (EF 30%) and pericardial effusion suggestive of associated pericarditis. She had a raised troponin level. Her relevant lab investigations to reveal a possible cause of myocarditis and pericarditis such as infectious and vasculitis workup all came back negative. Patient was treated in the cardiac critical unit (CCU) and her condition stabilized after 10 days with bed rest, anti-coagulation, anti-platelets, diuretics and ACE inhibitor. A repeated ECG upon discharge was normal, and a follow up echocardiogram 3 weeks later showed marked improvement with normal left ventricular ejection fraction (EF 45%). This serious adverse effect has already been reported in cases other than Multiple Sclerosis which were treated with the same medication. But only few cases reported in MS patients which mandates strict monitoring at baseline and on regular basis.