Iranian Association of Cardio-Oncology Bulletin shared on LinkedIn:
“Cardio-Oncology Bulletin – Issue #7
A monthly evidence update at the intersection of cardiology and oncology.
Case Highlight – When clinical recovery is not the whole story
ICI myocarditis can evolve quickly, but one of the harder questions comes later: how do we know when myocardial inflammation has truly resolved?
This month’s case by Matsui et al. stood out because the patient’s course did not move neatly in parallel. After nivolumab plus ipilimumab, Triple-M overlap syndrome developed with myocarditis, myositis, and clinically diagnosed myasthenia gravis. Cardiac involvement progressed from preserved LVEF and no cardiovascular symptoms to severe ventricular dysfunction, electrical instability, and cardiogenic shock despite early corticosteroid-based therapy.
Management ultimately required multimodal immunosuppression, including abatacept, IVIg, plasma exchange, and tacrolimus. But the most instructive part of the case was what happened after apparent stabilization: repeat endomyocardial biopsy still showed residual CD8⁺-predominant inflammation, prompting further treatment escalation. By Day 88, inflammatory infiltration had markedly decreased and LVEF had recovered to 56%, although low-grade histologic inflammation remained.
The uncertainty is important. A single case cannot establish the efficacy of abatacept, nor does it support routine serial biopsy in ICI myocarditis. What it does illustrate is that clinical status, biomarkers, ventricular function, electrical stability, and tissue-level inflammation may not recover at the same pace.
Clinically, the case reinforces a broader principle: in severe ICI myocarditis, apparent recovery should not automatically be equated with complete resolution of myocardial inflammatory activity.
Our editorial question:
When severe ICI myocarditis begins to improve, which combination of clinical, biomarker, imaging, and-selectively-histologic findings should define meaningful recovery and guide de-escalation of immunosuppression?”
Title: Abatacept for steroid-refractory fulminant immune checkpoint inhibitor myocarditis with triple M overlap syndrome: a case report with serial endomyocardial biopsy assessment
Authors: Ruriko Matsui, Kimi Sato, Kazuko Tajiri, Tomoko Ishizu
Read the full article.
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