Immune checkpoint inhibitor myocarditis mimicking Takotsubo cardiomyopathy on MPI
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Department of Radiology, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan Department of Cardiorenal and Cerebrovascular Medicine, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
Received Nov 11, 2020; accepted Nov 11, 2020 doi:10.1007/s12350-020-02444-2
A 73-year-old man with unresectable renal cell carcinoma was admitted for pulmonary tumor embolism and treatment with immune checkpoint inhibitors (ICIs; nivolumab and ipilimumab). Although he complained of no chest pain or abnormalities, electrocardiogram (ECG) showed ST elevation in leads II, III, aVF, and V2-V4 seven days after receiving ICIs. Blood analysis revealed markedly elevated creatine kinase, creatinine kinase myocardial band, and N-terminal pro-brain natriuretic peptide. The transthoracic echocardiogram demonstrated severe hypokinesis on the anterior-septal wall and akinesis at the apex. Acute myocardial infarction was initially suspected, and then emergency coronary angiography (CAG) was performed. However, CAG showed that no stenotic lesions and left ventriculography showed basal hyperkinesis and apical ballooning akinesis (Figure 1). Rest myocardial perfusion imaging (MPI) with technetium-99m tetrofosmin revealed significant defects in the distal septum and anterior walls and apex. Quantitative-gated single-photon emission computed tomography showed apical ballooning and severe decrease of wall motion and thickness in the entire mid to distal walls and apex (Figure 2). Although
Reprint requests: Takashi Norikane, MD, PhD, Department of Radiology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; [email protected] J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2020 American Society of Nuclear Cardiology.
the CAG and MPI findings were compatible with those of Takotsubo cardiomyopathy, cardiac magnetic resonance (CMR) imaging showed apical ballooning and akinesis in the in the entire mid to distal walls and apex; in addition, heterogeneous late gadolinium enhancement was observed in the entire mid to distal walls and apex (Figure 3). Endomyocardial biopsy confirmed the diagnosis of ICIs-related myocarditis. He complained of difficulty breathing and his vital signs had become unstable. He was treated with multidisciplinary therapy including steroids and discharged 5 weeks after the initial presentation. About 1 year after the event, the apical ballooning and akinesis of the entire mid to distal walls and apex persisted on CMR imaging (Figure 4). Immune therapy is a promising field and has been used in various clinical settings. Although ICIs have shown effectiveness in various malignant tumors and their use is expected to expand in the future, their side effects called immune-related adverse events (irAE) have become a problem. The incidence of cardiovascular irAE has been reported to be from 0.06% to 2.4%, with a higher risk in combination immunotherapy.1-3 The most common manifestation of cardiovascular irAE is myocarditis, and other manifestations include Takotsubo cardio
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