Resident Physician Stony Brook University Hospital Freeport , New York, United States
Disclosure(s):
Chelsea Amo Tweneboah, MD: No financial relationships to disclose
Background: 63-year-old man was diagnosed with stage IIIB squamous cell carcinoma in the right upper lobe, involving mediastinal lymph nodes. His history includes COPD, prior kidney and urothelial cancers, hyperlipidemia, hypothyroidism, heavy smoking (quit 2024), and past polysubstance use. He experienced worsening shortness of breath after a Levaquin course for pneumonia.
Methods: Patient presented to the emergency department with acute symptoms. The patient exhibited sinus tachycardia, tachypnea, and hypoxemia, necessitating 4 liters of oxygen via nasal cannula. Lactate levels were normal, and both CBC and coagulation profiles were unremarkable. Respiratory viral panel results were negative. EKG findings included a right bundle branch block with ST segment elevations in leads V1-V2 and aVR, alongside depressions in leads II, III, and aVL. CT PA excluded pulmonary embolism but revealed obstruction of the right upper lung airways, causing segmental atelectasis likely due to neoplasm or post-radiation changes. A Code H was activated, prompting urgent coronary angiography, which revealed non-obstructive coronary artery disease. Post-catheterization, the patient was initiated on a heparin infusion, loaded with aspirin 325 mg, and maintained on aspirin 81 mg daily. High-dose atorvastatin 80 mg was administered and the patient continued on metoprolol 12.5 mg with nitroglycerin prescribed as needed. TEE demonstrated a left ventricular ejection fraction of 48 percent with segmental wall motion abnormalities, including moderate hypokinesis of the septal apex and severe hypokinesis of the apical cap. CT imaging confirmed right upper lung collapse, an area of atelectasis, and small right lower lung consolidation, consistent with underlying malignancy and treatment effects
Outcome: After hospitalization, the patient was seen in the heart failure ambulatory clinic, and a repeat echocardiogram was obtained, which showed his ejection fraction had increased to 77 percent. The patient was continued on a Prednisone taper. He developed steroid-induced diabetes due to his extensive steroid course. He also developed fungal stomatitis, likely as a result of the steroids. The patient also dealt with renal failure as an outpatient and is in the process of undergoing a workup to determine whether the kidney failure is reversible or permanent. He currently participates in hemodialysis sessions. Additionally, according to the patient's oncologist, he has no active cancer and is pending a repeat CT scan. Future workup for the patient involves obtaining a cardiac MRI and repeating cardiac biomarkers every two weeks. The patient also plans to follow up with electrophysiology for evaluation of ICD placement and functionality.
Conclusion: Immune checkpoint inhibitors have shown significant benefits in oncology by targeting and eliminating proliferating cancer cells. ICIs are known to cause adverse effects, such as myocarditis. Diagnosing ICI myocarditis presents challenges, necessitating a comprehensive workup. Future research directions will focus on clinical trials to optimize the management of ICI-associated myocarditis.
