Tieying Hou, Tiffany Sheub, Matthew T Campbellc, Sumit K Subudhic, Jianjun Gaoc, Sangeeta Goswamic, Bilal A Siddiquid, Nicolas L Palaskase, Jean-Bernard Durande and Dongfeng Tana
Introduction: Immune checkpoint inhibitors (ICIs) are revolutionizing cancer therapy and have significantly improved the clinical outcome of multiple tumor types. ICIs-induced myocarditis is a rare, but potential fatal side effect that requires prompt treatment. The histopathological features of ICIs-induced myocarditis are not well characterized due to limited number of cardiac biopsy or autopsy performed.
Case presentation: Here we reported an autopsy finding from a 70-year-old white male with severe myocarditis induced by pembrolizumab administered during the treatment for high grade urothelial carcinoma. He initially presented with left eye ptosis, diplopia, fatigue, and shortness of breath for four days, followed by quickly developed brachycardia and complete heart block. He was treated with high-dose glucocorticoids, but his condition continued to deteriorate. He experienced two cardiopulmonary arrests and died on the fifth day of admission. Sections from heart show extensive myocarditis with dense mixed inflammatory infiltration and patchy myocyte necrosis. Focal endothelitis associated with scattered micro-hemorrhages are also identified.
Discussion and conclusion: We reviewed the published case reports or case series from 2015 to 2018 and identified 13 cases of ICIs-induced myocarditis with available histopathologic description. We summarized the finding of these 14 patients including our own case in this paper. Although lymphocytic myocarditis was present in all cases, some histopathologic features are not consistently observed. Better characterization of histopathologic features of ICIs-induced myocarditis will help us understand the mechanism of this fatal toxicity and lead to potentially more specific treatment.
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