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Case Series

Immune checkpoint inhibitor-induced myocarditis, myositis, myasthenia gravis and transaminitis: a case series and review

    Derrick Ho Wai Siu

    *Author for correspondence:

    E-mail Address: howai.siu@health.nsw.gov.au

    Department of Medical Oncology, St George Hospital, Kogarah, New South Wales, 2217, Australia

    National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, 2050, Australia

    Faculty of Medicine, The University of New South Wales, New South Wales, Australia

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    ,
    Robert Sean O'Neill

    Faculty of Medicine, The University of New South Wales, New South Wales, Australia

    Department of Medical Oncology, Sutherland Hospital, Caringbah, New South Wales, 2229, Australia

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    ,
    Carole A Harris

    Department of Medical Oncology, St George Hospital, Kogarah, New South Wales, 2217, Australia

    Faculty of Medicine, The University of New South Wales, New South Wales, Australia

    Department of Medical Oncology, Sutherland Hospital, Caringbah, New South Wales, 2229, Australia

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    ,
    Justine Wang

    Faculty of Medicine, The University of New South Wales, New South Wales, Australia

    Department of Neurology, St George Hospital, Kogarah, New South Wales, 2217, Australia

    Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, New South Wales, 2031, Australia

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    ,
    Luke Ardolino

    Faculty of Medicine, The University of New South Wales, New South Wales, Australia

    Department of Medical Oncology, The Kinghorn Centre, St Vincent's Hospital, Darlinghurst, New South Wales, 2010, Australia

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    ,
    Teesha Downton

    Department of Medical Oncology, The Wollongong Hospital, Wollongong, New South Wales, 2500, Australia

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    ,
    Matthew Tong

    Department of Medical Oncology, Sutherland Hospital, Caringbah, New South Wales, 2229, Australia

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    ,
    Jun Hee Hong

    Department of Medical Oncology, St George Hospital, Kogarah, New South Wales, 2217, Australia

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    ,
    Venessa Chin

    Department of Medical Oncology, The Kinghorn Centre, St Vincent's Hospital, Darlinghurst, New South Wales, 2010, Australia

    Single Cell and Computational Genomics Lab, The Garvan Institute of Medical Research, Darlinghurst, New South Wales, 2010, Australia

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    ,
    Philip R Clingan

    Department of Medical Oncology, The Wollongong Hospital, Wollongong, New South Wales, 2500, Australia

    University of Wollongong, New South Wales, Australia

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    ,
    Morteza Aghmesheh

    Department of Medical Oncology, The Wollongong Hospital, Wollongong, New South Wales, 2500, Australia

    University of Wollongong, New South Wales, Australia

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    &
    Hussein Soudy

    Department of Medical Oncology, St George Hospital, Kogarah, New South Wales, 2217, Australia

    Faculty of Medicine, The University of New South Wales, New South Wales, Australia

    Department of Medical Oncology, Sutherland Hospital, Caringbah, New South Wales, 2229, Australia

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    Published Online:24 Mar 2022https://doi.org/10.2217/imt-2021-0225

    Abstract

    Immune checkpoint inhibitors have been incorporated into the treatment of various malignancies. An increasing body of literature is reporting rare but potentially fatal adverse events associated with these agents. In this case series, the authors report the clinical features and outcomes of seven patients who received immune checkpoint inhibitors for different solid organ malignancies and developed a tetrad of immune-related myocarditis, myositis, myasthenia gravis and transaminitis. Herein the authors review the literature and describe the current diagnostic and management approach for this overlapping syndrome. The authors' series highlights the importance of a high index of clinical suspicion, prompt comprehensive investigations, early multidisciplinary team involvement and initiation of immunosuppressive therapy when immune-related adverse events are suspected.

    Plain language summary

    Cancer immunotherapy is used in the treatment of different cancer types. Immunotherapy activates the immune system to detect and attack cancer cells, but side effects may arise from the immune system inadvertently attacking normal tissues and organs. The increased use of immunotherapy has led to an increase in the reporting of rare but potentially life-threatening treatment-related side effects. In this case series, the authors report the clinical features and outcomes of seven patients who developed inflammation of the heart, muscles, nerve and muscle junctions and liver following treatment with immunotherapy. The authors review the scientific literature and discuss the current understanding of and management approach to this rare syndrome. The authors' report highlights the importance of a high degree of clinical suspicion, prompt comprehensive testing to confirm diagnosis, early involvement of experts from different specialties and early initiation of treatment in the management of this unique syndrome.

    Papers of special note have been highlighted as: • of interest; •• of considerable interest

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