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Nivolumab-induced myasthenia gravis in a patient with squamous cell lung carcinoma: Case report
Yu-Hsiu Chen1, Feng-Cheng Liu, Chang-Hung Hsu
1Division of Rheumatology/Immunology/Allergy, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center Department of Neurology, Tri-Service General Hospital, National Defense Medical Center Division of Pulmonary Medicine, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
Rationale:
Nivolumab (Nivo) is an immune checkpoint inhibitor that has been used to treat advanced melanoma, nonsmall cell lung carcinoma, and renal cell carcinoma since 2015. Nivo is associated with several side effects, including hepatitis, pneumonitis, acute renal failure, endocrine disorder, and other immune-related adverse events. Here, we describe the case of a 65-year-old man with squamous cell lung carcinoma who developed myasthenia gravis (MG) after a third Nivo infusion.
Patient Concerns:
A 65-year-old man with advanced squamous cell lung carcinoma developed ptosis, diplopia, drop head, and general weakness 5 days after a third Nivo infusion.
Diagnoses, Interventions, And Outcomes:
We diagnosed him with Nivo-related MG and myositis based on clinical symptoms, elevation of muscle enzymes, negativity for autoantibodies and exclusion of other diagnoses. Steroid treatment with methylprednisolone 1 mg/kg/d and pyridostigmine 60 mg twice a day was administered beginning at admission; however, the patient's condition progressively worsened, despite treatment. Respiratory failure developed 2 weeks after admission, and his family declined the use of a mechanical ventilator. The patient died on day 27 after the third Nivo infusion.
Lessons:
Nivo-related MG should be highly suspected in patients who develop ptosis, diplopia, and general weakness. The corresponding treatments include discontinuation of Nivo and steroid treatment with plasmapheresis. The disease course may be rapid and fatal. This report stresses the importance of awareness of this rare and lethal adverse effect while using nivolomab immunotherapy.
Insights
Nivolumab immunotherapy can cause myasthenia gravis (MG), a severe neurological side effect. Early suspicion and prompt treatment are crucial, as this condition can be fatal.
Area of Science:
- Immunology
- Neurology
- Oncology
Background:
- Nivolumab (Nivo) is an immune checkpoint inhibitor approved for advanced melanoma, lung, and renal cell carcinoma.
- Nivo is associated with immune-related adverse events, including hepatitis, pneumonitis, and endocrine disorders.
Observation:
- A 65-year-old man with squamous cell lung carcinoma developed ptosis, diplopia, and generalized weakness 5 days after his third Nivo infusion.
- Clinical symptoms, elevated muscle enzymes, and exclusion of other diagnoses led to a diagnosis of Nivo-related myasthenia gravis (MG) and myositis.
Findings:
- Despite treatment with methylprednisolone and pyridostigmine, the patient's condition worsened, leading to respiratory failure.
- The patient died 27 days after the third Nivo infusion, highlighting a rapid and fatal disease course.
Implications:
- Nivo-related MG must be suspected in patients presenting with ptosis, diplopia, and weakness.
- Prompt discontinuation of Nivo, along with steroid treatment and plasmapheresis, is recommended.
- This case underscores the importance of recognizing rare, potentially lethal adverse effects of nivolumab immunotherapy.
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