Zhang Bo, Gyawali Laxman, Liu Zengzhang, Du Huaan, Yin Yuehui
Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tian Wen Avenue, Nan'an District, Chongqing 401336, China.
Case Rep Cardiol. 2022 Aug 5;2022:4042909. doi: 10.1155/2022/4042909. eCollection 2022.
Immune checkpoint inhibitors (ICIs) have emerged in recent years as promising treatment options for several malignant tumors. However, ICI therapy has also been associated with various immune-related adverse events (irAEs), especially for patients with preexisting autoimmune status, which sometimes can be life-threatening. A 68-year-old woman diagnosed with metastatic thymoma was treated with camrelizumab, a new ICI, as her antitumor protocol. Eleven days after the first dose of camrelizumab, the patient was admitted to our hospital with symptoms of dyspnea, fatigue, and poor appetite. Workups on admission indicated dramatically elevated transaminase, troponin I, creatine kinase, and a new-onset conduction abnormality on electrocardiography. After detailed evaluation, ICI-related myocarditis, myositis, and hepatitis were diagnosed, and therapies including intravenous methylprednisolone were administered. Coronary angiography was performed to exclude acute coronary syndrome due to dynamic electrocardiography changes on day 3. She lapsed into a coma with respiratory muscle failure on the next day, which was highly suspected of myasthenic crisis. Mechanical ventilation and higher dose of methylprednisolone plus intravenous immunoglobulin were applied immediately. However, the third atrioventricular block occurred within the same day, and an urgent temporary pacemaker was placed. More seriously, refractory ventricular tachycardia (VT) occurred subsequently, and even multiple antiarrhythmic drugs used in combination failed to alleviate the VT storm. On day 5 of hospitalization, she suffered from ventricular fibrillation and died of cardiac arrest. In clinical practice, close follow-up should be conducted after ICI treatment, especially for patients already with or at high risk for autoimmune disorders. A multidisciplinary team approach is of importance for better management of patients with multiple organ involvement.
免疫检查点抑制剂（ICIs）近年来已成为多种恶性肿瘤颇具前景的治疗选择。然而，ICI治疗也与各种免疫相关不良事件（irAEs）相关，尤其是对于已有自身免疫状态的患者，这些不良事件有时可能危及生命。一名68岁被诊断为转移性胸腺瘤的女性接受了新型ICI卡瑞利珠单抗作为其抗肿瘤方案治疗。在首次使用卡瑞利珠单抗11天后，患者因呼吸困难、疲劳和食欲不佳入住我院。入院检查显示转氨酶、肌钙蛋白I、肌酸激酶显著升高，心电图出现新发传导异常。经过详细评估，诊断为ICI相关的心肌炎、肌炎和肝炎，并给予包括静脉注射甲泼尼龙在内的治疗。在第3天因动态心电图变化进行冠状动脉造影以排除急性冠状动脉综合征。次日她因呼吸肌衰竭陷入昏迷，高度怀疑为重症肌无力危象。立即应用机械通气、更高剂量的甲泼尼龙加静脉注射免疫球蛋白。然而，同一天内发生了三度房室传导阻滞，并紧急置入临时起搏器。更严重的是，随后出现了难治性室性心动过速（VT），即使联合使用多种抗心律失常药物也未能缓解VT风暴。住院第5天，她发生心室颤动，死于心脏骤停。在临床实践中，ICI治疗后应密切随访，尤其是对于已有自身免疫性疾病或处于自身免疫性疾病高风险的患者。多学科团队方法对于更好地管理多器官受累患者至关重要。
