Concurrent Nivolumab-Induced Myocarditis and Myasthenia Gravis: A Case Report

Area of Science:

• Oncology
• Immunology
• Cardiology

Background:

• Immune checkpoint inhibitors (ICIs) like nivolumab improve advanced melanoma survival but pose risks of immune-related adverse events (irAEs).
• Acral melanoma, a rare subtype, often presents late and necessitates aggressive treatment, including immunotherapy.
• Severe irAEs, such as cardiotoxicity and neuromuscular complications, can occur with ICI use.

Purpose of the Study:

• To report a rare case of nivolumab-induced myocarditis and myasthenia gravis in an elderly patient with acral melanoma.
• To highlight the importance of early recognition and management of these severe irAEs.

Main Methods:

• A 72-year-old male with Stage IIB acral melanoma received adjuvant nivolumab.
• Clinical presentation, diagnostic workup (including cardiac MRI, EMG), and treatment interventions were documented.
• Patient outcomes and subsequent cardiac events were monitored.

Main Results:

• The patient developed Grade 3 immune-related myocarditis and Grade 3 nivolumab-induced myasthenia gravis within 3 weeks of the first nivolumab dose.
• Treatment with corticosteroids and IVIG led to symptom resolution and improved cardiac function.
• The patient later experienced atrial fibrillation requiring hospitalization and cardioversion.

Conclusions:

• Nivolumab-induced myocarditis and myasthenia gravis necessitate high clinical suspicion for prompt diagnosis and management.
• Early ICI discontinuation and aggressive immunosuppression are critical for managing these severe irAEs.
• Multidisciplinary care and individualized risk-benefit assessments are vital, especially when considering ICI rechallenge.