Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA.
Am J Emerg Med. 2021 Aug;46:51-55. doi: 10.1016/j.ajem.2021.03.005. Epub 2021 Mar 8.
Case reports of immune checkpoint inhibitor (ICI) overlap syndrome of myasthenia gravis, myositis and myocarditis, are increasing in the published literature. This is a potentially fatal adverse event of ICIs and emergency physicians need to be familiar with this triad when patients present to the emergency department (ED).
We performed a retrospective chart review of the electronic medical record between September 1, 2016 to March 9, 2020. We identified patients with the overlap syndrome who presented to our ED.
Seven patients were identified. Most were female and treated with a programmed cell death-1 inhibitor. Most patients presented with abnormal vital signs and the most common symptoms were ptosis, diplopia, dyspnea and fatigue. Most required supplemental oxygen and had a prolonged length of stay. All received steroids in addition to other immunomodulators. Two patients died.
Presence of one of the diagnosis should lead to evaluation for the others. Suspicion should be raised by patients presenting with ptosis, muscular weakness, fatigue and dyspnea. Early recognition of this triad can allow for early administration of high-dose glucocorticoids (1-2 mg/kg of prednisone or equivalent), which is the mainstay of treatment. However, it is likely that patients will need further immunomodulators and therefore, will need hospitalization.
Emergency physicians should be aware of this potentially lethal triad in cancer patients receiving ICIs. The life-saving interventions in the ED include recognizing the triad, airway support, administration of high-dose glucocorticoids, and early involvement of a multidisciplinary team.
在已发表的文献中，免疫检查点抑制剂（ICI）重叠综合征（包括重症肌无力、肌炎和心肌炎）的病例报告正在增加。这是 ICI 的一种潜在致命不良反应，当患者到急诊科就诊时，急诊医生需要熟悉这三联征。
我们对 2016 年 9 月 1 日至 2020 年 3 月 9 日的电子病历进行了回顾性图表审查。我们确定了在我们的急诊科就诊的重叠综合征患者。
共发现 7 名患者。大多数为女性，接受程序性死亡 1 抑制剂治疗。大多数患者表现出异常生命体征，最常见的症状是上睑下垂、复视、呼吸困难和疲劳。大多数患者需要补充氧气，且住院时间延长。所有患者均接受了类固醇治疗，此外还接受了其他免疫调节剂治疗。两名患者死亡。
出现其中一种诊断应提示评估其他两种诊断。当患者出现上睑下垂、肌肉无力、疲劳和呼吸困难时，应怀疑存在这种三联征。早期识别这种三联征可以早期给予大剂量糖皮质激素（1-2mg/kg 泼尼松龙或等效药物），这是主要的治疗方法。然而，患者很可能需要进一步的免疫调节剂治疗，因此需要住院治疗。
接受 ICI 治疗的癌症患者的急诊医生应意识到这种潜在的致命三联征。急诊科的救命干预措施包括识别三联征、气道支持、给予大剂量糖皮质激素以及尽早让多学科团队参与。
