SHM Converge Scientific Abstract ePoster Gallery-Immune Checkpoint Inhibitor Myocarditis: Check Yourself Before You Wreck Yourself

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This case describes an 81-year-old man with angiosarcoma on nivolumab who developed acute shortness of breath, edema, pulmonary edema, elevated BNP, and a mildly elevated but stable troponin one week after his infusion. Despite preserved left ventricular ejection fraction on transthoracic echocardiogram, cardiac MRI showed diffuse late gadolinium enhancement, leading to the diagnosis of immune checkpoint inhibitor (ICI) myocarditis. He was treated with pulse-dose steroids and nivolumab was permanently stopped.<br /><br />The presentation highlights that ICI myocarditis can occur within months of starting therapy but may appear as late as two years after initiation. It is associated with PD-1, CTLA-4, and PD-L1 inhibitors, with the highest risk in combination therapy. Symptoms can include chest pain and dyspnea, and cardiac function may remain preserved.<br /><br />Diagnosis can be made through one of three pathways: pathology-proven myocarditis; symptoms plus elevated biomarkers and MRI findings of late gadolinium enhancement; or symptoms plus biomarkers/ECG changes, echocardiographic abnormalities, and exclusion of acute coronary syndrome by coronary angiography.<br /><br />Treatment is urgent and empiric: stop immunotherapy indefinitely and begin high-dose steroids for three days followed by a prolonged taper. Other immunomodulatory treatments such as IVIG, infliximab, and plasmapheresis have been reported in case studies. ICI myocarditis is rare but highly lethal, with reported mortality around 50%. Key takeaways are to suspect it even with preserved EF, recognize the diagnostic criteria, and treat promptly.

Asset Subtitle

Cooper B. Kersey

Meta Tag

Author List Cooper B. Kersey, Tomio Tran

Category Clinical Vignettes

Concept Immune Checkpoint InhibitorAssociated Myocarditis

Concept Myocarditis

Concept Corticosteroids

Concept Pulse-Dose Steroids

Concept Immune Checkpoint Inhibitor

Distinguished Non-Finalist

Presenter Organization University of Washington Internal Medicine Residency

Presenting Author Cooper B. Kersey

Track Adult

Keywords

immune checkpoint inhibitor myocarditis

nivolumab

angiosarcoma

late gadolinium enhancement

cardiac MRI

pulmonary edema

elevated BNP

preserved ejection fraction

high-dose steroids

myocarditis mortality

Immune Checkpoint InhibitorAssociated Myocarditis

Myocarditis

Corticosteroids

Pulse-Dose Steroids

Immune Checkpoint Inhibitor