Pembrolizumab-induced necrotizing diaphragmatic myositis
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Abstract
Pembrolizumab, an anti-PD1 antibody, is increasingly used for the treatment of non-small cell lung cancer. We report a severe and poorly described adverse effect of this therapy: necrotizing myopathy with diaphragmatic and myocardial involvement.
A 77-year-old male was diagnosed with metastatic lung adenocarcinoma and started a regimen with chemotherapy along with Pembrolizumab. Two weeks after the second cycle, he was admitted to the hospital due to acute myocarditis and hypercapnic respiratory failure. Treatment with glucocorticoids and Mycophenolate improved his cardiac condition. However, hypercapnic respiratory failure persisted, as well as orthopnea and generalized muscle weakness including bulbar musculature. After comprehensive evaluation including diaphragmatic ultrasound, electromyogram, and biopsy, he was diagnosed with autoimmune necrotizing myopathy with diaphragmatic and myocardial involvement. Treatment with intravenous immunoglobulins and non-invasive mechanical ventilation was added. However, he experienced respiratory deterioration, resulting in death.
This case exemplifies the importance of early recognition and intensive treatment of this serious adverse effect. Due to the increasing use of these therapies, it is expected to see a parallel increase in their adverse effects in the coming years.
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2024-06-15
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References
- 1. Kao JC, Brickshawana A, Liewluck T. Neuromuscular complications of Programmed Cell Death-1 (PD-1) inhibitors. Curr Neurol Neurosci Rep 2018; 18(10):63. 2. Kadota H, Gono T, Shirai Y, et al. Immune checkpoint inhibitor-induced myositis: a case report and literature review. Curr Rheumatol Rep 2019; 21(4):10. 3. Sekiguchi K, Hashimoto R, Noda Y, et al. Diaphragm involvement in immune checkpoint Inhibitor related myositis. Muscle Nerve 2019; 60(4):E23–E25. 4. Haddox CL, Shenoy N, Shah KK, et al. Pembrolizumab induced bulbar myopathy and respiratory failure with necrotizing myositis of the diaphragm. Ann Oncol 2017; 28(3):673-675. 5. Claus J, Van Den Bergh A, Verbeek S, et al. Pembrolizumab-induced necrotizing myositis in a patient with metastatic non-small-cell lung cancer: a case report. Lung Cancer Manag 2017; 8(2):LMT10.