DILATED CARDIOMYOPATHY ASSOCIATED WITH IMMUNE CHECKPOINT INHIBITOR, NIVOLUMAB

Abstract

TYPE: Case Report TOPIC: Pharmacotherapeutics INTRODUCTION: Cardiomyopathy related to immune checkpoint inhibitor (ICI) is an infrequent adverse event, and the mechanism is still unclear. The most plausible mechanism is via hyper-infiltration of T- cells that damage the myocardial tissue. CASE PRESENTATION: An 88-year-old female with metastatic melanoma receiving treatment with Nivolumab and Talimogene laherparevec (intralesional), presented with of progressive dyspnea for five days. The patient was diagnosed with acute hypoxic respiratory failure secondary to acute heart failure. Initial laboratory values included brain natriuretic peptide (BNP) level of 530 pg/ml, and high sensitivity troponin level of 130 ng/L. Electrocardiogram showed normal sinus rhythm without evidence of acute ST-changes. Computed tomography angiogram of the chest confirmed evidence of bilateral pleural effusions without evidence of pulmonary embolism (Figure 1). Patient underwent left thoracocentesis performed by interventional radiology. Echocardiogram showed LVEF of 20-25% with severe global hypokinesis. Pleural fluid analysis was consistent with transudate. There was no evidence of malignancy on cytology or infection on gram stain. Cardiac magnetic resonance imaging was performed indicating LVEF of 23%, but no evidence of myocarditis or any infiltrative process. Left heart catherization showed no evidence of coronary artery disease. The medical recommendation was to discontinue Nivolumab therapy. DISCUSSION: Our clinical case highlights the importance of long-term follow-up of cancer patients consuming ICI since there are rare cardiac adverse events that presents after several months. Unfortunately, our patient died within 30 days of discharge. CONCLUSIONS: Cardiomyopathy is a rare, but potentially life-threatening complication of ICI therapy and should be considered when discussing treatment modalities with patients, especially the elderly. DISCLOSURE: Nothing to declare. KEYWORD: nivolumab