SHM Converge Scientific Abstract ePoster Gallery-A Diagnostic Puzzle: Hypercalcemia and Cardiac Findings in a Patient Receiving Immune Checkpoint Inhibitors

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An 81-year-old man with urothelial carcinoma developed prolonged malaise, anorexia, intermittent fever, leukocytosis, hypercalcemia, and troponin elevation shortly after completing immune checkpoint inhibitor (ICI) therapy with atezolizumab and tiragolumab. He had already been treated for presumed infection and had a prior hospitalization for suspected pneumonia and mild ICI-related myocarditis, but symptoms recurred.<br /><br />Workup showed marked hypercalcemia with normal PTH, PTHrP, and 25-OH vitamin D, but elevated 1,25-OH vitamin D, suggesting an inflammatory/granulomatous process rather than malignancy-related hypercalcemia. Cardiac MRI showed myocardial edema and findings initially concerning for amyloidosis. PET/CT demonstrated diffuse inflammatory uptake in the myocardium, synovium, and pleura, raising suspicion for sarcoid disease. Endomyocardial biopsy ultimately revealed both cardiac amyloidosis and active cardiac sarcoidosis.<br /><br />The patient’s hypercalcemia improved with IV fluids and calcitonin, and he had further clinical improvement after prednisone was started. Follow-up PET/CT three months later showed improvement in cardiac sarcoidosis and resolution of apical uptake.<br /><br />This case highlights several key points: delayed immune-related adverse events can occur months after ICI therapy ends; ICI-related cardiac sarcoidosis is rare and can mimic infection or sepsis; and pre-treatment cardiac screening may be useful, especially in patients with pre-existing conduction disease or other cardiac risk factors.

Asset Subtitle

Hadi Roudsari

Meta Tag

Author List Hadi Roudsari, Sam Brondfield

Category Clinical Vignettes

Concept Immune Checkpoint Inhibitor

Concept Immune-Related Adverse Event

Concept Hypercalcemia

Concept Granulomatous Disease

Concept Sarcoidosis

Distinguished Non-Finalist

Presenter Organization University of California San Francisco

Presenting Author Hadi Roudsari

Track Adult

Keywords

urothelial carcinoma

immune checkpoint inhibitor

atezolizumab

tiragolumab

cardiac sarcoidosis

cardiac amyloidosis

hypercalcemia

troponin elevation

myocardial edema

prednisone

Immune Checkpoint Inhibitor

Immune-Related Adverse Event

Hypercalcemia

Granulomatous Disease

Sarcoidosis