The Terrible Triad of Checkpoint Inhibition: A Case Report of Myasthenia Gravis, Myocarditis, and Myositis Induced by Cemiplimab in a Patient with Metastatic Cutaneous Squamous Cell Carcinoma

Case Reports in Immunology
Nikeshan JeyakumarL Maximilian Buja

Abstract

We report a case of a patient with squamous cell carcinoma (SCC) who developed myasthenia gravis (MG), myositis, and myocarditis after receiving cemiplimab, an anti-PD-1 immune checkpoint inhibitor (ICI). Case Presentation. An 86-year-old man with metastatic periocular SCC presented with decreased vision in the left eye, severe fatigue, and lower back and bilateral hip pain 3 weeks after receiving cemiplimab. Within hours, he developed dysphonia, pharyngeal secretions, and dysphagia, necessitating intubation. Endomyocardial biopsy revealed active lymphocyte-mediated necrosis consistent with ICI-induced myocarditis. Anti-striated muscle and anti-acetylcholine receptor antibodies were elevated, consistent with myositis and myasthenia gravis. Despite plasma exchange therapy, steroids, and intravenous immunoglobulin, he died from cardiac arrest. The presence of myasthenia gravis, myocarditis, or myositis should prompt evaluation for all three toxicities as they may represent an overlap syndrome. The severity of these immunotoxicities highlights the need for clinicians to suspect multiple simultaneous adverse effects of ICIs.

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Citations

Jan 3, 2021·Orbit·Edward J Wladis, Madhavi L Kambam
Nov 14, 2020·Arthritis & Rheumatology·Laura C Cappelli, Clifton O Bingham
Apr 1, 2021·Drugs·Blake H FortesLauren A Dalvin
Apr 18, 2021·Journal of Clinical Neuroscience : Official Journal of the Neurosurgical Society of Australasia·Renato OliveiraMiguel Oliveira Santos
Jun 10, 2021·Brain and Behavior·Wei ChengPing Chen
Aug 24, 2021·Tumori·Fabio CaninoMassimo Dominici
Aug 27, 2021·Frontiers in Cardiovascular Medicine·Rishi RikhiRohit Moudgil
Oct 14, 2021·Expert Opinion on Drug Safety·Alessia VillaniMassimiliano Scalvenzi

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Methods Mentioned

BETA
coronary artery bypass
biopsy

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Carcinoma, Squamous Cell

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