IMMUNE CHECKPOINT INHIBITORS

Presentation and Diagnosis

Jane is a 64-year-old female patient who was diagnosed with metastatic (to the lung) clear cell renal cancer in 2014.

Treatment

Initially she underwent a radical nephrectomy and then was treated with sunitinib and later with axitinib. When she was noted to have new disease in the lung, she was started on nivolumab. Jane received the first dose without incident.

Cardiotoxicity Mitigation and Management

When Jane came in for cycle 2, she was noted to have elevated LFTs, and her advanced practitioner (AP) held her treatment that day. A few days later, she developed chest pain while walking her dog. She went to her local emergency room and was noted to have sinus tachycardia with non-specific T wave and ST-segment changes, including TT segment elevation on EKG. Labs included an elevated WBC, elevated eosinophils, elevated ESR, and elevated troponin. Jane’s AP was concerned about nivolumab-associated myocarditis, and she recommended Jane be admitted to the hospital.

While hospitalized, Jane had an echocardiogram was noted to have a decreased ejection fraction and spherical shaped ventricle. A myocardial biopsy was attempted, and during the procedure, the myocardium was perforated and a myocardial drain was placed. Jane was initiated on high-dose steroids, but she did not experience any improvement, so her AP started her on infliximab. Her symptoms, as well as her troponin and ESR all improved, and she was discharged from the hospital. 

During the next week, Jane began to experience swelling of her lower extremities and shortness of breath. She returned to the ER and was admitted to ICU with heart failure. The providers were not able to maintain her mean arterial pressures (MAPs), and she died a few days later.