Table 1.
Patient Characteristics and Clinical Course
| Case 1 | Case 2 | Case 3 | Case 4 | |
|---|---|---|---|---|
| Sex | Male | Male | Male | Female |
| Age | 72 | 69 | 63 | 76 |
| Pre-hospital symptom | Presyncope | Fever, Chest pain | Fever, Chest pain | Fatigue, Dyspnea |
| Cancer | Renal cell carcinoma | Prostate cancer | Lung cancer | Lung cancer |
| Metastasis | Liver, Lung | Bone | - | - |
| ICI |
Avelumab (anti-PD-L1) Nivolumab (anti-PD-1) |
Pembrolizumab (anti-PD-1) | Atezolizumab (anti-PD-L1) | Atezolizumab (anti-PD-L1) |
| Comorbidities | Hypertension, Diabetes | Hypertension | None | Hypertension, IHD |
| Time between last ICI administration and onset of myocarditis | 18 days | 893 days | 13 days | 11 days |
| Decompensated heart failure | No | Yes | Yes | Yes |
| Cardiogenic shock | Yes | Yes | Yes | Yes |
| Arrythmia | VT | Complete AVB, VT, PAF | Complete AVB | VT, PAF |
| Associated other irAE | Hepatitis, myositis | None | None | None |
| QRS width, ms | 148 | 147 | 172 | 80 |
| LVEF (on admission) | 40 | 17 | 10 | 10 |
| Laboratory data | ||||
| CK (on admission), U/L | 5724 | 2450 | 3859 | 101 |
| CK (peak), U/L | 5724 | 5103 | 3859 | 101 |
| CK-MB (on admission), U/L | 96 | 365 | 61 | 5 |
| CK-MB (peak), U/L | 141 | 428 | 61 | 7 |
| Troponin T (on admission), ng/mL | 1.871 | 48.118 | 11 | 0.226 |
| Troponin T (peak), ng/mL | 5.343 | 48.118 | 15.561 | 0.358 |
| BNP (on admission), pg/mL | 456.2 | 921.7 | 388.9 | 1357.3 |
| CRP (on admission), mg/dL | 1.09 | 9.32 | 9.47 | 0.59 |
| Endomyocardial biopsy |
CD3+ T-cells (CD8 > CD4) CD68+ histiocytes A few CD20+ B-cells A few eosinophils High Tenascin C High PD-L1 |
CD3+ T cell (CD8 > CD4) CD68+ histocytes A few CD20+ B-cells Neutrophils / Eosinophils High Tenascin C High PD-L1 |
CD3+ T-cells (CD4 = CD8) CD68+ histiocytes A few CD20+ B-cells Moderate Tenascin C Moderate PD-L1 |
CD3+ T-cells (CD8 > CD4) Rare CD68+ histiocytes Rare CD20+ B-cells Low Tenascin C Low PD-L1 |
| Treatment | ||||
| MCS | None | VA-ECMO, IABP | VA-ECMO, Impella CP | VAV-ECMO, Impella CP |
| Immunosuppressants |
Pulse MP (1000 mg, 3 days) Followed by PRD (1 mg/kg) |
Pulse MP (1000 mg, 3 days) Followed by PRD (10 mg) |
Pulse MP (1000 mg, 3 days) |
Pulse MP (1000 mg, 3 days) Followed by PRD (1 mg/kg) |
| Outcome | Death | Death | Death | Alive |
| Cause of death | VT | Heart failure / MOF | Intracerebral hemorrhage | - |
AVB atrioventricular block, BNP B-type natriuretic peptide, CD cluster of differentiation, CK creatine kinase, CRP C-reactive protein, ECMO extracorporeal membrane oxygenation, IABP intra-aortic balloon pump, ICI immune check point inhibitor, IHD ischemic heart disease, irAE immune-related adverse effect, LVEF left ventricular ejection fraction, MCS mechanical circulatory support, MOF multiple organ failure, MP methylprednisolone, PAF paroxysmal atrial fibrillation, PD-L1 programmed cell death ligand 1, PRD prednisolone, VA veno-arterial, VAV veno-arterial-venous, VT ventricular tachycardia