Differentiating between immune checkpoint inhibitor-induced myocarditis and cardiac metastasis in a cardio-oncology patient presenting with myocardial infarction: A case report

Abstract

BACKGROUND

Cardiovascular diseases and cancer are leading causes of morbidity and mortality. Patients with malignancies are at increased risk for cardiovascular complications including acute coronary syndromes, chemotherapy or radiation therapy related complications and cardiac metastasis.

CASE SUMMARY

We present a case of a 47-year-old female with metastatic cancer on immunotherapy presented with anterior ST elevation myocardial infarction followed by emergent percutaneous coronary intervention in the left anterior descending artery. Echocardiography after 72 hours showed thickening of inferior wall and cardiac magnetic resonance depicted inflammation and necrosis attributable to either cardiac metastasis or immunotherapy induced myocarditis. Biopsy was not performed because of treatment with antiplatelet drugs and a definite diagnosis was achieved after probationary administration of high-dose intravenous methylprednisolone that led to recovery.

CONCLUSION

In patients with malignancy, chemotherapy-induced cardiovascular complications and cardiac metastasis are common concerns and may coexist with common acute cardiovascular diseases including acute coronary syndromes. In such cases clinical suspicion aided by multimodality imaging is crucial for the diagnosis. A multidisciplinary team approach is required for prompt initiation of the appropriate treatment.

Keywords: Immune check-point inhibitors; Nivolumab; Myocarditis, Cardiac metastasis; Cardiac magnetic resonance; Echocardiography; Case report

Core Tip: This case report presents a cardio oncology patient who presented with an acute coronary syndrome. However, the clinical presentation as well as the echocardiography findings were suspicious for an alternative diagnosis including immune checkpoint inhibitor-induced myocarditis or cardiac metastasis. Cardiac magnetic resonance aided the final diagnosis and the initiation of the appropriate treatment by the multidisciplinary team. The case highlights the significance of multimodality imaging for the management of cardio-oncology patients.