Anti-PD1 associated fulminant myocarditis after a single pembrolizumab dose: the role of occult pre-existing autoimmunity
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Ferrata Storti Foundation
Martinez-Calle, N. (Nicolas); Rodriguez-Otero, P. (Paula); Villar-Fernández, S. (Sara); et al. "Anti-PD1 associated fulminant myocarditis after a single pembrolizumab dose: the role of occult pre-existing autoimmunity". Haematologica. 103 (7), 2018, e319
Multiple myeloma is a promising candidate for anti-PD1 checkpoint inhibitor therapy.1–3 Results of phase I trials of pembrolizumab, in combination with lenalidomide or pomalidomide in relapsed/refractory patients have shown encouraging results. These trials showed a 35% and 65% response rate in patients already refractory to IMIDs with a median PFS of 7.2 and 14 months for the lenalidomide and pomalidomide combinations, respectively.4,5 These positive results prompted the activation of phase III trials, which are currently underway in relapsed ( identifier 02576977) and first-line setting ( identifier 02579863). Immune-related adverse events (irAE) as a result of uncontrolled activation of autoreactive T-cells,6 are the most important emerging safety issues of checkpoint inhibitors. Myocarditis is rare among the irAE; however, several cases of lethal immune-related myocarditis have recently been published.7–9 The Nivolumab patient database has revealed an incidence of myocarditis of 0.09% in over 20,000 patients already treated;7 however, this figure may be an underestimation since only symptomatic cases were recorded. Myocarditis seems to be frequent with the nivolumab-ipilimumab combination (0.27%), with two reports of a lethal outcome.8 To the best of our knowledge, no fatal cases have been reported with pembrolizumab or nivolumab as single checkpoint inhibitor agents. Here, we report a newly diagnosed multiple myeloma patient who developed a lethal immune-related myocarditis after a single dose of pembrolizumab, which was combined with lenalidomide and dexamethasone, not with other checkpoint inhibitors.

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