Chest Pain With Immune Checkpoint Inhibitor Therapy: Harnessing the Power of Multimodality Imaging

Immune checkpoint inhibitors (ICIs) such as pembrolizumab improve outcomes in metastatic non-small-cell lung cancer but can cause immune-related adverse events. Cardiovascular immune-related adverse events, including pericarditis, are rare and often underrecognized.

A 53-year-old woman with recurrent metastatic lung adenocarcinoma on pembrolizumab presented with worsening pleuritic chest pain. Prior admissions attributed symptoms to pneumonia, pulmonary embolism, or malignancy. Laboratory studies showed elevated inflammatory markers and transaminitis; troponin was negative. Serial chest computed tomography demonstrated progressive pericardial thickening. Transthoracic echocardiography revealed a thickened pericardium, and cardiac magnetic resonance imaging confirmed pericardial inflammation without myocarditis. Liver biopsy supported concomitant ICI-related hepatitis. She was treated with nonsteroidal anti-inflammatory drugs, colchicine, and corticosteroids, with permanent discontinuation of ICIs. Follow-up imaging showed resolution.

ICI-associated pericarditis requires high clinical suspicion, particularly in patients with lung cancer with overlapping etiologies for chest pain. Multimodality imaging and retrospective review of serial studies are critical for diagnosis.

Consider pericarditis in patients on ICI therapy with persistent pleuritic chest pain. Serial imaging review and early multimodality cardiac evaluation improve diagnostic accuracy and guide management.