Durvalumab-associated Late-onset Myocarditis Successfully Treated with Corticosteroid Therapy

Durvalumab-Induced Myocarditis and Dilated Cardiomyopathy in a Patient With Non-small Cell Lung Cancer: A Diagnostic Conundrum

Immune checkpoint inhibitors have been a therapeutic oncological breakthrough in managing diverse malignancies. We present a 78-year-old male with stage IIIb non-small cell lung cancer (NSCLC) managed by concurrent chemotherapy with carboplatin/pemetrexed and radiotherapy followed by monthly durvalumab injections. He presented to the hospital with shortness of breath and fluid overload after eight months of starting durvalumab. Workup, including laboratory investigations, coronary angiography, and stress myocardial magnetic resonance imaging, increased our suspicion for the diagnosis of durvalumab-induced myocarditis and nonischemic dilated cardiomyopathy. He was managed with aggressive diuresis and pulse dose steroids with an improvement in his symptoms and his cardiac function. This case illustrates an under-reported clinical side effect in the era of advancement in oncological immunotherapy.

Severe cardiotoxicity induced by osimertinib in a patient with EGFR-mutated adenocarcinoma of the lung

A man in his 70s was detected an infiltrative shadow on the right lung. A bronchoscopy confirmed the diagnosis of adenocarcinoma of the lung, classified as cT2bN2M0 stage IIIA, with a deletion mutation in EGFR exon 19. Weekly carboplatin plus paclitaxel was administered in combination with thoracic radiotherapy, followed by maintenance therapy with durvalumab for 1 year. Four months later, he was diagnosed with a recurrence of adenocarcinoma in the lung. He started treatment with osimertinib. Six months after initiating osimertinib, a chest CT revealed bilateral pleural effusion and expansion of the inferior vena cava. Eleven months later, he entered our emergency department with progressive dyspnoea. A chest CT showed bilateral massive pleural effusion and cardiac enlargement. He was diagnosed with osimertinib-induced cardiac failure. Osimertinib was discontinued, and echocardiology demonstrated a gradual improvement in cardiac function. It is necessary to take care of osimertinib-related cardiotoxicity.

Durvalumab-Associated Myocarditis Initially Presenting With Sinus Bradycardia Progressing Into Complete Heart Block

Durvalumab is a monoclonal antibody that blocks programmed cell death ligand-1 (PD-L1). It has been recently approved for the treatment of advanced urothelial and non-small cell lung cancer (NSCLC) with a more favorable side effect profile compared to traditional chemotherapy agents. We present a case of durvalumab-induced myocarditis complicated by complete heart block (CHB). A 71-year-old male with a history of atrial flutter status post ablation, type 2 diabetes mellitus, hypertension, and non-small cell lung carcinoma (NSCLC) recently started on durvalumab, presented with new sinus bradycardia on electrocardiogram (EKG). His initial labs were notable for a troponin T of 207 ng/L (normal range ≤50). Transthoracic echo (TTE) and computed tomography angiography (CTA) of the coronaries were unremarkable. The hospital course was complicated by CHB on telemetry for 15 minutes. Given hemodynamic instability, cardiac magnetic resonance imaging (MRI) could not be obtained. The patient received transvenous pacing. Electrophysiology and cardiology-oncology were consulted to evaluate for pacemaker implantation as well as management for durvalumab-induced myocarditis. Methylprednisolone 1000 mg intravenous (IV) was started with an improvement in troponin levels but without improvement in CHB. His course was further complicated by polymorphic ventricular tachycardia prompting the placement of a permanent dual-chamber pacemaker. The patient was discharged on a prednisone taper, and durvalumab was discontinued. A diagnosis of durvalumab-induced myocarditis was made based on elevated troponin levels, with the exclusion of coronary artery disease with CTA of the coronaries. The persistence of conduction abnormalities despite treatment with steroids leads to the placement of a permanent pacemaker. Durvalumab falls under the category of immune checkpoint inhibitor (ICI) therapy which are novel agents that have more favorable side effect profiles compared to traditional chemotherapeutic agents. A review of the literature shows myocarditis with arrhythmias as a potentially rare side effect of ICI therapy. Corticosteroid therapy seems to be promising as a potential therapy.

Case Report: Acute Myocarditis Due to PD-L1 Inhibitor Durvalumab Monotherapy in a Patient With Lung Squamous Cell Carcinoma

Background

Durvalumab, as a PD-L1 inhibitor, is commonly used for the treatment of various cancers. Adverse events associated with the therapy include hepatitis, nephritis, dermatitis, and myocarditis. Especially, myocarditis as an adverse event after PD-L1 inhibitor therapy is characterized for its low incidence and high mortality.

Case Summary

Here we present a rare case of a 67-year-old male with lung squamous cell carcinoma complicated with empyema who experienced myocarditis after only PD-L1 inhibitor durvalumab monotherapy. He presented with markedly decrease left ventricular ejection fraction, elevated Natriuretic peptide BNP, Troponin T, Troponin I, ESR, CRP and interleukin-6. The electrocardiogram showed sinus tachycardia, low voltage of limb leads, T wave inversion in anterior waves and V1-V3 QS type. Myocardial injury occurred in a short period and quickly returned to normal after glucocorticoids therapy.

Conclusion

This case report is of clinical value for the treatment of PD-L1 related myocarditis.