A case report of fulminant eosinophilic myo-pericarditis related to checkpoint inhibitors complicated by acute heart failure and cardiac tamponade.

Background: Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment but are associated with various adverse effects, including myocarditis, with mortality rates up to 50%. We report a case of fatal ICI-related fulminant eosinophilic myo-pericarditis complicated by tamponade in a 69-year-old man with metastatic lung adenocarcinoma.

Case Summary: Two weeks after receiving one dose of pembrolizumab, the patient presented with sudden chest pain and dyspnoea. Examination revealed tachycardia, hypotension, and hypoxia. Electrocardiogram showed a new right bundle branch block and ST depressions in the precordial leads with an elevated troponin I of 49.69 ng/mL. Echocardiogram demonstrated globally reduced function and pericardial effusion, suggesting impending tamponade. Despite aggressive resuscitative efforts, the patient rapidly decompensated and ultimately went into cardiac arrest and passed away. Autopsy was performed with pathology demonstrating necrotizing eosinophilic myocarditis related to ICIs. Other potential causes of eosinophilic myocarditis, such as drug hypersensitivity, were felt less likely given lack of drugs associated with eosinophilic myocarditis. Eosinophilic granulomatosis with polyangiitis and hypereosinophilic syndrome were also less likely based on American College of Rheumatology criteria as well as the absence of peripheral eosinophilia.

Discussion: This case emphasizes the need for awareness of eosinophilic myo-pericarditis as a potential complication of ICI therapy. It underscores the value of early endomyocardial biopsy in unstable patients with suspected acute myocarditis, 'fast-tracking' treatment initiation. It also highlights the rapid progression of cardiac complications in ICI-related myocarditis and the potential for tamponade, emphasizing the low threshold for consideration of myocarditis and treatment in patients initiating or receiving ICIs.