Abstract Details

Title Triple M: A case of Nivolumab-induced myasthenic crisis, myocarditis and myositis

Topic Neuromuscular and Clinical Neurophysiology (EMG)

Presentation(s) P15 - Poster Session 15 (12:00 PM-1:00 PM)

Poster/Presentation
Number 1-004

Objective To present the case of a patient with rare neurologic sequelae of an immune checkpoint inhibitor.

Background The use of immune checkpoint inhibitors is becoming more widespread in oncologic treatment. Neurologic side effects of immune checkpoint inhibitors such as Nivolumab are rare but serious and include myasthenic crisis, myositis, encephalitis, polyneuropathy, and radiculitis. Few case reports describe the serious neurologic complications of Nivolumab, and even fewer report concurrence of the triad of myositis, myasthenic crisis, and myocarditis in the same patient.

Design/Methods A single case report.

Results An 86-year-old man with history of well-controlled ocular myasthenia gravis presented to the ER with five days of weakness, diffuse myalgias, ptosis, and diplopia. He recently initiated Nivolumab for renal cell carcinoma, the first dose occurring one month prior and the second dose nine days prior. On initial evaluation, he was found to have ptosis and ophthalmoparesis bilaterally. He had neck flexion weakness and proximal limb weakness ranging from 4/5 to 4+/5. Lab work revealed a creatinine kinase of 5,443 and elevated troponin. He was treated with steroids, IVIg, and mestinon for suspected myositis, myocarditis, and myasthenia exacerbation secondary to Nivolumab. Despite treatment his symptoms worsened and he developed worsening limb weakness, bulbar dysfunction, and respiratory symptoms requiring intubation. Cardiac function worsened and he was found to have complete heart block requiring pacemaker placement. After treatment with plasmapheresis, symptoms stabilized. Over the next four months he continued to have some recovery of neurologic function but did not return to baseline and ultimately died from progression of renal cell carcinoma.

Conclusions This case demonstrates the rare triple M triad of myasthenia crisis, myositis, and myocarditis in a single patient treated with Nivolumab. As more patients with cancer are treated with immune modulating therapies neurologists must be aware of these potential adverse events, which can be life-threatening.

Authors/Disclosures
Katelyn Oliveira, DO (Southcoast Brain & Spine Center) PRESENTER	No disclosure on file
Kara Stavros, MD, F�鶹��ýӳ��	Dr. Stavros has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Springer Healthcare LLC. Dr. Stavros has received personal compensation in the range of $500-$4,999 for serving as an officer or member of the Board of Directors for Rhode Island Medical Society.
Jacob Didion, MD	No disclosure on file

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