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Myositis and left psoas major muscle bleeding leading to spontaneous muscular haematoma: case report A 71-year-old man developed myositis and left psoas major muscle bleeding leading to spontaneous muscular haematoma during treatment with ipilimumab and nivolumab for recurrent pancreatic adenocarcinoma. The muscle bleeding and spontaneous muscular haematoma were also attributed to methylprednisolone and enoxaparin sodium [not all routes stated]. The man, who had recurrent pancreatic adenocarcinoma (recurrence was first suspected in November 2015), started receiving nivolumab [Opdivo] 1 mg/Kg in a hospital, along with other antineoplastics. In August 2016, ipilimumab [Yervoy] 3 mg/Kg was started with a schedule of 2 cycles. Eight weeks after the last dose of nivolumab and ipilimumab, he developed myositis and myasthenia. On 31 October 2016, he presented to the emergency room with a high level of creatine kinase (CK). His CK level continued to increase, and the myositis and myasthenia symptoms worsened. Investigations showed positive serum anti-Ro-52 antibody, increased levels of ESR and hypersensitive CRP. An electromyogram detected active myogenic damage. A biopsy of the right quadriceps femoris muscle revealed necrosis of skeletal muscle fibres and inflammation in the interstitial area and small vessels. The myasthenia continued to aggravate. Due to involvement of swallowing muscles and respiratory muscles, he exhibited dysphagia and respiratory failure. On 10 November 2016, the man started receiving IV methylprednisolone at an initial dose of 500 mg/day for 3 days, followed by 60mg daily. Over the next few weeks, his symptoms improved. Eventually, CK level normalised. Four days post methylprednisolone initiation, he experienced acute and progressive low back pain radiating to the left lower limb. Additionally, a drop in haemoglobin (Hb) level was noted. An X-ray imaging showed massive haematoma of the left psoas major muscle secondary to bleeding in this area. He was receiving preventive anticoagulant treatment with enoxaparin sodium [enoxaparin] at 670 U/10kg body weight every 12 hours, due to his bed confinement status and low level of plasma albumin. No coagulation dysfunction was observed, and he did not experience any trauma. A physical examination did not reveal any petechia or bruising. Following discontinuation of enoxaparin sodium and methylprednisolone, the bleeding ceased. A CT-angiography showed no leakage of contrast from the vessels. His Hb level remained stable. On 9 December 2016, he was discharged in a stable condition with prescription of tapered oral glucocorticoids [specific drug not stated]. Two months later, he died of underlying pancreatic cancer recurrence. His myositis remained stable at the time of death. Author comment: "[T]his is the first case report of lifethreatening myositis and spontaneous muscular haematoma associated with combined [ipilimumab and nivolumab]. "Moreover, those patients who received anticoagulant also underwent glucocorticoid pulse treatment, which may sugges