SHM Converge Scientific Abstract ePoster Gallery-When Immunotherapy Goes Awry: Steroid-Refractory Immune Checkpoint Inhibitor-Induced Myocarditis

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An 81-year-old woman with a history of stage III melanoma treated with nivolumab developed progressive generalized weakness, dyspnea, and left-sided neck pain about two weeks after her first dose. At an outside hospital, she had markedly elevated troponin-I and was initially treated for NSTEMI. She also tested positive for AChR antibodies, raising concern for overlap with myasthenia gravis, and was started on IVIG, steroids, and pyridostigmine. Her troponinemia was then attributed to immune checkpoint inhibitor (ICI)-induced myocarditis. After discharge to rehab on a steroid taper, her symptoms recurred, and she was transferred for further care.<br /><br />On admission, she received high-dose IV methylprednisolone and another course of IVIG. Cardiology later recommended escalation to abatacept and ruxolitinib because troponins were not adequately improving with steroids alone. Cardiac workup showed elevated troponin and BNP, but normal EKG, chest X-ray, and echocardiogram with preserved ejection fraction.<br /><br />The patient improved after five doses of abatacept: troponins declined, respiratory failure and weakness resolved, and she was discharged home on a prednisone taper without major cardiac events. Troponin normalized shortly after discharge.<br /><br />The case emphasizes that ICI-induced myocarditis is rare but highly lethal, with reported mortality of 25–50%, and may occur even when cardiac imaging is normal. Clinicians should maintain a high index of suspicion in patients on checkpoint inhibitors who develop troponin elevation and treat aggressively early. Steroids alone may be insufficient, and newer therapies such as abatacept and ruxolitinib may improve outcomes when used promptly.

Asset Subtitle

Laurel M. Smeins

Meta Tag

Author List Joel Kline, Laurel M. Smeins

Category Clinical Vignettes

Concept Immune Checkpoint InhibitorAssociated Myocarditis

Concept Immune Checkpoint Inhibitor Therapy

Concept Troponin

Concept High-Dose Corticosteroid

Concept Myocardial Injury

Distinguished Non-Finalist

Presenter Organization University of Iowa Hospitals and Clinics, Department of Internal Medicine

Presenting Author Laurel M. Smeins

Track Adult

Keywords

immune checkpoint inhibitor myocarditis

nivolumab

troponin elevation

myasthenia gravis overlap

AChR antibodies

abatacept

ruxolitinib

high-dose steroids

IVIG

melanoma

Immune Checkpoint InhibitorAssociated Myocarditis

Immune Checkpoint Inhibitor Therapy

Troponin

High-Dose Corticosteroid

Myocardial Injury