Third degree atrio-ventricular blockade during a myocarditis occurring under anti-PD1 : Case report and literature review

• Published in: La revue de medecine interne 2020-04, Vol.41 (4), p.284
• Main Authors: Prevel, R, Colin, G, Calès, V, Renault, P A, Mazieres, J
• Format: Article
• Language: fre
• Subjects: Aged, 80 and over; Antineoplastic Agents, Immunological - adverse effects; Antineoplastic Agents, Immunological - therapeutic use; Atrioventricular Block - chemically induced; Atrioventricular Block - complications; Atrioventricular Block - pathology; Carcinoma, Squamous Cell - complications; Carcinoma, Squamous Cell - drug therapy; Diabetes Mellitus, Type 2 - complications; Humans; Immune Checkpoint Inhibitors - adverse effects; Immune Checkpoint Inhibitors - therapeutic use; Immunotherapy - adverse effects; Lung Neoplasms - complications; Lung Neoplasms - drug therapy; Male; Myocarditis - chemically induced; Myocarditis - complications; Myocarditis - pathology; Nivolumab - adverse effects; Nivolumab - therapeutic use; Programmed Cell Death 1 Receptor - antagonists & inhibitors; Programmed Cell Death 1 Receptor - immunology
• ISSN: 1768-3122
• DOI: 10.1016/j.revmed.2019.12.023

Immune Checkpoint Inhibitor (ICI) therapy is now a standard of care in numerous cancers with very promising results. Nevertheless, adverse events, and especially immune-related adverse events (irAEs) not reported during clinical trials, are emerging and can be life-threatening. We report here a teachable case of a 80 year-old man, of third-degree atrioventricular block consecutive to myocarditis associated with the administration of nivolumab (anti-PD1) monotherapy. Myocarditis occurring during ICI treatment is a rare but potentially lethal event. Daily serum troponin level seems to predict ICI-related myocarditis but interpretation could be difficult in the context of associated myositis. Echocardiography and cardiac MRI are also useful but can remain negative. Electrocardiogram is a cornerstone of myocarditis diagnosis. In case of cardiac involvement, continuous heart rhythm monitoring should be performed in addition to the administration of high-dose corticosteroids therapy and the cessation of ICI therapy. Add-on treatments should be discussed with a well-trained multidisciplinary team.