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Necrotising myositis and acute heart failure: case report A 60-year-old man developed necrotizing myositis during treatment with pembrolizumab for grade IVA pulmonary squamous cell carcinoma. He also developed acute heart failure during treatment with unspecified steroids for muscle inflammation [durations of treatments to reactions onsets and outcomes not stated]. The man, who had a history of hypertension, ischemic cardiopathy, meningioma (treated with radiotherapy) and grade IVA pulmonary squamous cell carcinoma (p40+, Calretinin-, WT1-, Ck7-, CK20-) with pleural-pericardial involvement, was treated with a single dose of pembrolizumab 200mg. After 7 days, he developed walking difficulties and neck pain. Therefore, he was admitted to emergency care. His blood tests showed raised creatine kinase (CK) (20,000 U/L) and troponin was mildly elevated (40 ng/L). Clinical examination showed limbs proximal weakness and head drop. Electromyography revealed diffuse denervation along with myopathic signs, which suggested of muscle inflammation. He was hydrated and was started on a high dose of unspecified steroids daily [route and dose not stated]. Before receiving steroid serum troponin was stable around 35 ng/L. After 1 day, he developed mild swallowing disturbances and diplopia. CT brain ruled out major cerebral events. CK level was decreased to 9000 U/L, mild strength improvement in upper limbs was noted without any sign of heart failure. A muscle biopsy of the left biceps muscle showed a severe acute inflammatory myopathy. Histological findings with hematoxylin-eosin staining showed some necrotic-degenerating muscle fibers with a wide interstitial and perivascular inflammatory cellular infiltration. Thus, a diagnosis was confirmed with necrotising myositis. After 2 days of starting steroid, he developed acute heart failure and was admitted in the ICU. His blood cardiac troponins were over 5000 times the normal levels. The man underwent external pacemaker implantation because of sudden onset of atrioventricular block and severe reduction in heart-rate. He was additionally treated with vasoactive support. Unfortunately, he died after 1 day [cause of death not stated]. The most recent blood test showed a reduction of CK (4688 U/L) and increase in troponin rate (70225 ng/L). A doppler echocardiography performed at that time revealed a severe reduction in cardiac output, septal hypokinesia and marked left ventricular apex hypokinesia. Peverelli L, et al. Severe inflammatory myopathy in a pulmonary carcinoma patient treated with Pembrolizumab: An alert for myologists. Journal of Neuromuscular Diseases 803517461 7: 511-514, No. 4, 18 Sep 2020. Available from: URL: http://doi.org/10.3233/JND-200504

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Reactions 28 Nov 2020 No. 1832