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292 Immune checkpoint inhibitor induced overlapping cardiac and neuromuscular toxicities: Highlight of early diagnosis, early initiation of immunosuppressive therapy and multidisciplinary management
  1. Ho Wai Siu1,
  2. Robert O’Neill2,
  3. Matthew Tong2,
  4. JunHee Hong1,
  5. Carole A Harris3,
  6. Morteza Aghmesheh4 and
  7. Hussein Soudy5
  1. 1St George Hospital, Sydney, Australia
  2. 2The Sutherland Hospital, Sydney, Australia
  3. 31. St George Hospital, 2. University of New South Wales, Sydney, Australia
  4. 41. The Wollongong Hospital 2. University of Wollongong, Wollongong, Australia
  5. 51. St George Hospital 2. University of New South Wales, Sydney, Australia


Background The use of immune checkpoint inhibitors (ICIs) against programmed cell death protein -1 (PD-1), its ligand (PD-L1) and cytotoxic T- lymphocyte associated protein 4 (CTLA4) have been increasing. Immune induced myocarditis, myositis and myasthenia gravis are rare but potentially severe complications from these agents. Here we report 3 cases of ICI induced myocarditis, myositis, myasthenia gravis and transaminitis as a cluster, and highlights early diagnosis, prompt initiation of steroid sparing immunosuppressive therapy and multidisciplinary management.

Methods Three patients received anti-PD-1 ICIs developed cardiac, neuromuscular complications and transaminitis within 4 weeks after initiation. Clinical data were retrospectively reviewed from medical records.

Results All patients had elevated cardiac enzymes, developed complete heart block and underwent coronary catheterisation and pacemaker insertion. All patients developed myositis and myasthenia gravis (table 1) and were managed by multi-disciplinary team involving oncology, cardiology and neurology. Single-fibre electromyography was performed to confirm presence of myositis. One of three patients had positive acetylcholinesterase antibody, anti- muscle specific kinase antibody was negative in all cases. All patients developed grade 2–3 transaminitis with normal bilirubin. All patients received high-dose steroids. Steroid sparing therapy including intravenous immunoglobulin and mycophenolate mofetil were used early in 2 cases and was associated with rapid recovery of toxicities.

Abstract 292 Table 1

Patient characteristics, management and outcome of ir-AEs

Conclusions ICI induced myocarditis can be associated with myositis, myasthenia gravis and transaminitis. A high index of suspicion, comprehensive investigations and early involvement of multi-disciplinary teams are key to early accurate diagnosis. In steroid refractory cases, we propose early initiation of steroid sparing immunosuppressive therapy after 3 days.

Consent Written informed consent was obtained from the patient for publication of this abstract and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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