Betz Yaqub, Zayed Selveras, Moroni Francesco, LeGallo Robin, Abbate Antonio
Division of Cardiovascular Medicine, University of Virginia, PO Box 8000662, Charlottesville, VA 22908, USA.
Division of Pathology, University of Virginia, 1215 Lee St., Charlottesville, VA 22908, USA.
Eur Heart J Case Rep. 2025 Aug 16;9(8):ytaf400. doi: 10.1093/ehjcr/ytaf400. eCollection 2025 Aug.
Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment but are associated with various adverse effects, including myocarditis, with mortality rates up to 50%. We report a case of fatal ICI-related fulminant eosinophilic myo-pericarditis complicated by tamponade in a 69-year-old man with metastatic lung adenocarcinoma.
Two weeks after receiving one dose of pembrolizumab, the patient presented with sudden chest pain and dyspnoea. Examination revealed tachycardia, hypotension, and hypoxia. Electrocardiogram showed a new right bundle branch block and ST depressions in the precordial leads with an elevated troponin I of 49.69 ng/mL. Echocardiogram demonstrated globally reduced function and pericardial effusion, suggesting impending tamponade. Despite aggressive resuscitative efforts, the patient rapidly decompensated and ultimately went into cardiac arrest and passed away. Autopsy was performed with pathology demonstrating necrotizing eosinophilic myocarditis related to ICIs. Other potential causes of eosinophilic myocarditis, such as drug hypersensitivity, were felt less likely given lack of drugs associated with eosinophilic myocarditis. Eosinophilic granulomatosis with polyangiitis and hypereosinophilic syndrome were also less likely based on American College of Rheumatology criteria as well as the absence of peripheral eosinophilia.
This case emphasizes the need for awareness of eosinophilic myo-pericarditis as a potential complication of ICI therapy. It underscores the value of early endomyocardial biopsy in unstable patients with suspected acute myocarditis, 'fast-tracking' treatment initiation. It also highlights the rapid progression of cardiac complications in ICI-related myocarditis and the potential for tamponade, emphasizing the low threshold for consideration of myocarditis and treatment in patients initiating or receiving ICIs.
免疫检查点抑制剂（ICI）彻底改变了癌症治疗方式，但会引发各种不良反应，包括心肌炎，死亡率高达50%。我们报告一例69岁转移性肺腺癌男性患者发生致命的ICI相关暴发性嗜酸性粒细胞性心肌心包炎并伴有心脏压塞。
在接受一剂派姆单抗两周后，患者出现突发胸痛和呼吸困难。检查发现心动过速、低血压和低氧血症。心电图显示新发右束支传导阻滞及胸前导联ST段压低，肌钙蛋白I升高至49.69 ng/mL。超声心动图显示整体功能降低及心包积液，提示即将发生心脏压塞。尽管进行了积极的复苏努力，患者病情仍迅速恶化，最终心脏骤停并死亡。进行了尸检，病理显示与ICI相关的坏死性嗜酸性粒细胞性心肌炎。鉴于缺乏与嗜酸性粒细胞性心肌炎相关的药物，嗜酸性粒细胞性心肌炎的其他潜在病因，如药物过敏，可能性较小。根据美国风湿病学会标准以及外周血嗜酸性粒细胞缺乏，嗜酸性肉芽肿性多血管炎和高嗜酸性粒细胞综合征的可能性也较小。
该病例强调需要认识到嗜酸性粒细胞性心肌心包炎是ICI治疗的一种潜在并发症。它强调了对疑似急性心肌炎的不稳定患者进行早期心内膜活检的价值，即“快速启动”治疗。它还突出了ICI相关心肌炎中心脏并发症的快速进展以及心脏压塞的可能性，强调在开始或接受ICI治疗的患者中考虑心肌炎及治疗的阈值较低。
