Hatem Elabd, MD, PhD
Critical Care Medicine and Nephrology Specialist
TriHealth-Good Samaritan Hospital
Cincinnati, Ohio, United States
Disclosure information not submitted.
Timothy Mccann, MD
Internal Medicine Resident
TriHealth-Good Samaritan Hospital
Cincinnati, Ohio, United States
Disclosure information not submitted.
Stephen Beerman, MD
Attending, Internal Medicine
TriHealth-Good Samaritan Hospital
Cincinnati, Ohio, United States
Disclosure information not submitted.
Mennallah Elkholi, MD
MPH
University of Cincinnati, United States
Disclosure information not submitted.
Title: Dilated Cardiomyopathy Associated with Immune Checkpoint Inhibitor Nivolumab
Case Report Body:
Introduction: Cardiomyopathy related to immune checkpoint inhibitor (ICI) is an infrequent adverse event, and the mechanism is still unclear. The most plausible mechanism is via hyper-infiltration of T- cells that damage the myocardial tissue. The fatal outcome has been reported in case reports.
Description: An 88-year-old Caucasian female with a history of hypertension, and metastatic melanoma currently receiving treatment with Nivolumab and Talimogene (intralesional), presented to the emergency room with a chief complaint of progressively worsening dyspnea for five days duration. She also complained of orthopnea, dry cough, and pleuritic chest pain that worsened when lying flat. Physical examination on presentation was notable for evidence of jugular venous distention, decreased breath sounds at bilateral lung bases with fine crackles throughout mid lobes. A cardiovascular exam noted an S3 with a regular rate and rhythm. No lower extremity edema was noted. Initial laboratory values included a brain natriuretic peptide (BNP) level of 530 pg/ml and high sensitivity troponin level of 130 ng/L. A computed tomography angiogram of the chest confirmed evidence of bilateral pleural effusions without evidence of pulmonary embolism. An echocardiogram showed new onset of dilated cardiomyopathy, LVEF of 20-25% with severe global hypokinesis. She had no known cardiac history and was on minimal medication prior to presentation.
The workup for the cause of the new-onset systolic heart failure was unrevealing; Cardiac magnetic resonance imaging showed LVEF of 23%, but no evidence of myocarditis or an infiltrative process. Left heart catheterization indicated severe global hypokinesis and no evidence of coronary artery disease. Management included continuing guideline-directed medical therapy and follow-up as well as the discontinuation of immunotherapy. Unfortunately, the patient died unexpectedly 32 days after discharge. No repeated echocardiogram was performed prior to death. No autopsy was performed.
Discussion: Cardiomyopathy is a rare, but potentially life-threatening complication of ICI therapy and should be considered when discussing treatment modalities with patients, especially the elderly.