A Fatal Case of Pembrolizumab-Induced Myocarditis in Non–Sma
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Immune channel inhibitor-induced myocarditis is rare, and its management is challenging. Recently, guidelines were established for all ICIs, yet they do not take into account individual drug toxicities or screening protocols for prevention. This report presents a rare case of rapidly progressive pembrolizumab-induced fatal myocarditis in an initially asymptomatic patient.

A 77-year-old asymptomatic white male with stage IV non–small cell lung cancer (NSCLC), who had completed his second cycle of pembrolizumab, carboplatin, and pemetrexed 3 weeks earlier, was referred to the emergency department for observation from an outpatient cancer center due to new-onset right bundle branch block and premature ventricular contractions detected before port-a-cath placement. Stat electrocardiogram showed ST-segment elevation in V3 to V5 anteroseptal leads with a new intraventricular block.

Emergent troponin testing revealed a level of 37.81 ng/ml. Anticoagulation therapy and cardiac catheterization were initiated after an episode of hypotension and tachycardia and showed normal coronary arteries. Pulmonary embolism was subsequently ruled out with computed tomography–angiography of the chest. Serial troponin level tests were ordered. Transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging were scheduled. The patient developed stable sustained ventricular tachycardia (VT) with hypotension, and amiodarone was administered. Sinus rhythm was eventually restored.

Conclusively, Pembrolizumab, an anti–PD-1 checkpoint inhibitor, has proven efficacious in the treatment of many cancers, most notably melanoma, and NSCLC. Although rare, rapid progression of fatal myocarditis, as in our patient, is serious and warrants a better understanding of its etiology, screening, and management to reduce adverse outcomes.

Source: https://www.sciencedirect.com/science/article/pii/S2666084920301303
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