SHM Converge Scientific Abstract ePoster Gallery-The Age of Immunotherapy: Immune Related Adverse Events With Overlap

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This case describes a 79-year-old Caucasian man with metastatic melanoma who developed a severe autoimmune overlap syndrome after starting immune checkpoint inhibitor therapy with ipilimumab and nivolumab. Within 3–4 days of his first immunotherapy session, he began to experience progressive generalized weakness, dysphagia, and shortness of breath.<br /><br />On admission, he had proximal muscle weakness, oral thrush, and hypotension responsive to IV fluids. Laboratory studies showed markedly elevated muscle enzymes, including CPK, LDH, and aldolase, suggesting inflammatory myositis. Imaging confirmed widespread metastatic disease, including brain, lung, axillary, and bone involvement. EMG demonstrated inflammation of proximal, distal, and facial muscles without classic myasthenia gravis findings.<br /><br />He was initially treated with high-dose methylprednisolone for suspected immune-related myositis and later received IVIG when overlap with myasthenia gravis was suspected. Although his proximal strength improved briefly, he then developed worsening dysphagia, dysarthria, diplopia, and respiratory distress requiring ICU care. He was treated with pulse-dose steroids and plasmapheresis for presumed myasthenic crisis. His CPK and aldolase levels decreased, and acetylcholine receptor antibodies returned positive, supporting a myasthenia gravis overlap syndrome. Despite aggressive treatment, his frailty and clinical decline led to comfort-focused care.<br /><br />The report highlights that immune checkpoint inhibitors, while improving melanoma survival, can cause rare but life-threatening neurologic immune-related adverse events. Myositis and myasthenia gravis may occur together as an overlap syndrome, making diagnosis and management challenging. Early recognition and multidisciplinary intervention are emphasized as critical to improving outcomes in these severe complications.

Asset Subtitle

Tissa Bijoy George

Meta Tag

Author List Anthony J Nicolas, Khushboo Singh, Peta Gay a Ricketts, Tissa Bijoy George

Category Clinical Vignettes

Concept Immune-Related Adverse Event

Concept Myositis

Concept Myasthenia Gravis

Concept Immune Checkpoint Inhibitor

Concept Triple M Syndrome

Distinguished Non-Finalist

Presenter Organization Upmc

Presenting Author Tissa Bijoy George

Track Adult

Keywords

metastatic melanoma

immune checkpoint inhibitor

ipilimumab

nivolumab

autoimmune overlap syndrome

immune-related myositis

myasthenia gravis

dysphagia

plasmapheresis

acetylcholine receptor antibodies

Immune-Related Adverse Event

Myositis

Myasthenia Gravis

Immune Checkpoint Inhibitor

Triple M Syndrome