Case of pembrolizumab-induced myocarditis presenting as torsades de pointes with safe re-challenge.

Authors

Dae Hyun Lee
Merna Armanious
Jessica Huang
Daniel Jeong
Mihaela Druta
Michael G Fradley

Publication/Presentation Date

9-1-2020

Abstract

INTRODUCTION: Pembrolizumab is an immune checkpoint inhibitor targeting the programmed death receptor with clinical effect on multiple malignancies including sarcoma. Associated cardio-toxicities include myocarditis, cardiomyopathy, heart failure, and arrhythmias. Although in most cases of immune checkpoint inhibitor cardiotoxicity the offending agent is discontinued, we report a case of successful and safe re-challenge with a checkpoint inhibitor in a patient with mild myocarditis.

CASE REPORT: We describe a 37-year-old female with alveolar soft part sarcoma, metastatic to the lungs on cycle 13 of pembrolizumab who presented with dyspnea, cough, and vague chest discomfort. Telemetry showed bigeminal bradycardia that transitioned to self-terminating torsades de pointes. Cardiac MRI showed subtle patchy T2 signal increase within the left ventricular septum without late gadolinium uptake, suggesting mild focal myocarditis.Management and outcome: The patient was started on a steroid taper without additional arrhythmias. We have re-challenged the patient who safely tolerated re-challenge with pembrolizumab despite an episode of torsades de pointes and documented myocarditis. She continues to receive pembrolizumab at seven months after the initial event without further cardiovascular events.

DISCUSSION: To the best of our knowledge, this is the first reported case of successful re-challenge of pembrolizumab after an episode of myocarditis. In patients with mild myocarditis and no evidence of left ventricular dysfunction, re-challenge may be a viable option. However, close monitoring for the development of heart failure, cardiomyopathy, or serious arrhythmias is necessary to ensure patient safety.

Volume

26

Issue

6

First Page

1544

Last Page

1548

ISSN

1477-092X

Published In/Presented At

Lee, D. H., Armanious, M., Huang, J., Jeong, D., Druta, M., & Fradley, M. G. (2020). Case of pembrolizumab-induced myocarditis presenting as torsades de pointes with safe re-challenge. Journal of oncology pharmacy practice : official publication of the International Society of Oncology Pharmacy Practitioners, 26(6), 1544–1548. https://doi.org/10.1177/1078155220904152

Disciplines

Medical Education | Medicine and Health Sciences

PubMedID

32089073

Department(s)

USF-LVHN SELECT Program, USF-LVHN SELECT Program Students

Document Type

Article