SHM Converge Scientific Abstract ePoster Gallery-Immune-Checkpoint-Inhbitor Induced Triple M Overlap Syndrome: Myasthenia Gravis, Myositis, and Myocarditis in a Patient With Lung Adenocarcinoma

Immune-Checkpoint-Inhbitor Induced Triple M Overlap Syndrome: Myasthenia Gravis, Myositis, and Myocarditis in a Patient With Lung Adenocarcinoma

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This case describes a 77-year-old woman with recurrent lung adenocarcinoma who developed immune checkpoint inhibitor–induced triple M overlap syndrome (TMOS) six weeks after starting nivolumab and ipilimumab. She presented with one week of severe bilateral ptosis, dysarthria, fatigue, and generalized weakness. On exam, she had ophthalmoplegia, proximal weakness, and a positive ice pack test, suggesting myasthenia gravis. Labs showed elevated CK, troponin, and liver enzymes, and ECG revealed a new right bundle branch block, raising concern for concurrent myositis and myocarditis.<br /><br />She was treated with high-dose IV methylprednisolone followed by oral prednisone, underwent seven sessions of plasma exchange, and was started on pyridostigmine. Despite treatment, she had no meaningful improvement in bulbar or respiratory weakness. Her troponin and ECG abnormalities improved, but her respiratory status worsened, with declining negative inspiratory force, hypotension, and hypoxemia. She required ICU transfer and high-flow oxygen. Her course progressed to somnolence and overall decline, and after goals-of-care discussions, the family chose comfort-focused care. She died during hospitalization.<br /><br />The discussion highlights that TMOS is a rare but increasingly recognized and highly lethal complication of immune checkpoint inhibitor therapy. It involves the simultaneous occurrence of myasthenia gravis, myositis, and myocarditis. Although myocarditis may improve, that does not necessarily signal recovery of neuromuscular or respiratory function. The authors emphasize the importance of early recognition and early goals-of-care conversations, given the reported mortality of up to 43.8%.

Asset Subtitle

Edward B. Starling

Meta Tag

Author List Annie Massart, Edward B. Starling, Mary Ann K. Hall, Matthew Dean

Category Clinical Vignettes

Concept Triple M Overlap Syndrome

Concept Myasthenia Gravis

Concept Myositis

Concept Myocarditis

Concept Immune Checkpoint Inhibitor

Distinguished Non-Finalist

Presenter Organization Emory University School of Medicine

Presenting Author Edward B. Starling

Track Adult

Keywords

immune checkpoint inhibitor

triple M overlap syndrome

nivolumab

ipilimumab

myasthenia gravis

myositis

myocarditis

lung adenocarcinoma

plasma exchange

high-dose corticosteroids

Triple M Overlap Syndrome

Myasthenia Gravis

Myositis

Myocarditis

Immune Checkpoint Inhibitor