Today we discussed a case that demonstrates an interesting side effect of immunomodulatory chemotherapy. Thank you to Dr. O’Quinn for joining us! The case we discussed today was a young female patient being treated for ovarian cancer with pembrolizumab, who presented with positional chest pain and was found to be in ventricular tachycardia with elevated cardiac enzymes. Her workup included a left heart catheterization that was negative for coronary artery disease, and a CT chest that was negative for pulmonary embolus.
One point that we discussed was the role for contrast to enhance echocardiograms. The use of contrast can be helpful to allow the cardiologists to get a more accurate estimate of LV ejection fraction and assess for presence of regional wall motion abnormalities; in this case the patient had a TTE without contrast that was difficult to interpret, and the addition of contrast provided a study consistent with reduced LV ejection fraction and moderately decreased RV systolic function.
Ultimately this patient’s presentation was thought to be myocarditis secondary to pembrolizumab toxicity. Pembrolizumab is a PD1 inhibitor, and many side effects of this therapy are related to activation of the immune system.
Cardiac side effects of this therapy are relatively rare, but have been reported in case series with presentations similar to our patient. Histologic studies show that pathology involves a lymphocytic infiltrate causing inflammation in cardiac tissue, which can manifest with arrhythmias and heart failure.
The primary treatment for autoimmune side effects of PD1 inhibitors is usually steroids. This patient was treated with corticosteroids and improved initially, but was unable to wean. Next steps in management were discussed with multiple institutions and departments within our own institution, as this is a newly described entity with limited experience. Ultimately, she was given infliximab and did really well!
Varracchi et al. Cardiotoxicity of immune checkpoint inhibitors. ESMO Open. 2017 Oct 26;2(4):e000247. doi: 10.1136/esmoopen-2017-000247.