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Neurological Rehabilitation

(Kiosk 3) A Rare Case of Immunotherapy Induced Myasthenia Gravis, Myocarditis, and Myositis

Thursday, November 16, 2023
12:45 PM – 2:15 PM CT

    Primary Author(s)

  • Harmandeep K. Grewal, DO (she/her/hers)

    Resident Physician
    UCLA David Geffen SOM/ UCLA Medical Center/VA Greater Los Angeles Health
    Los Angeles, California

    • Co-Author(s)

  • Merideth Byl, DO, MBA

    Resident Physician
    UCLA David Geffen SOM/ UCLA Medical Center/VA Greater Los Angeles Health
    Culver City, California

  • MJ

    Michelle Jin, MD

    Resident Physician
    UCLA David Geffen SOM/ UCLA Medical Center/VA Greater Los Angeles Health
    Los Angeles, California

  • KV

    Kim Vu, MD

    Physician
    n/a
    Los Angeles, California

Case Diagnosis: 75 year old male with lung adenocarcinoma treated with immune checkpoint inhibitor (ICI) nivolumab and developed myasthenia gravis (MG), myocarditis, and myositis.

Case Description or Program Description: Patient noted diplopia four days post-treatment with carboplatin, paclitaxel, and nivolumab. Symptoms progressed and subsequently admitted for bilateral ptosis, diplopia, shortness of breath, and increased negative inspiratory function consistent with MG. Additional symptoms included bulbar weakness and dysphonia.
Workup included negative acetylcholine receptor and anti-muscle specific kinase antibodies and a positive ice pack test. Electromyography not consistent with MG, however, was clinically diagnosed due to progression of muscle fatigue in setting of nivolumab therapy.
Hospital course complicated by hypercapnia with increasing oxygen requirement, myocarditis, myositis. Patient received plasma exchange, intravenous immune globulin, and pyridostigmine for MG and solumedrol for myocarditis. Respiratory status improved with average volume assured pressure support. Patient then admitted to the acute rehabilitation unit.
At initial evaluation, patient required total assistance for transfers, ambulation, and stairs with therapy limited by tachycardia. Also with neck and trunk fatigue with edge of bed sitting.

Setting: Acute Rehabilitation Unit (ARU)

Assessment/Results: At discharge, patient ambulated 500 feet with single point cane and was independent with bed mobility and transfers. Three months after discharge, continues to have intermittent diplopia and residual weakness in neck and upper back.

Discussion (relevance): There are few case reports of MG, myocarditis, and myositis after ICI therapy. A systematic review of 65 patients with MG after ICI revealed occurence at a median of four weeks in 97%; 37% developed concurrent myositis, and death occurred in 38%. A separate study of 10,277 patients treated with ICI showed 12 patients developed MG after nivolumab. Among the 12 patients, four had myositis, three had myocarditis, and one had both.

Conclusions: Knowledge of this fatal complication of ICIs, such as nivolumab, can assist physiatrists in caring for and initiating rehabilitation of cancer patients in the ARU.