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Life-threatening immune checkpoint inhibitor-induced myocarditis and myasthenia gravis overlap syndrome treated with abatacept: a case report
  1. Chelby Wakefield1,
  2. Carl Shultz2,
  3. Brijesh Patel2 and
  4. Midhun Malla3
  1. 1Internal Medicine, West Virginia University, Morgantown, West Virginia, USA
  2. 2West Virginia University, Morgantown, West Virginia, USA
  3. 3Hematology-Oncology, West Virginia University, Morgantown, West Virginia, USA
  1. Correspondence to Dr Chelby Wakefield; chelby.wakefield{at}


We present here the second documented case of severe immune checkpoint inhibitor-induced myocarditis successfully treated with abatacept. The patient was started on pembrolizumab for stage IIIA malignant melanoma, and after the first dose was admitted for worsening shortness of breath and weakness. Her symptoms were refractory to high-dose steroids and she decompensated rapidly necessitating cardiopulmonary resuscitation and subsequent intubation and mechanical ventilation. Intravenous immunoglobulin and plasmapheresis did not invoke significant improvement, so abatacept was then initiated. She began to show improvement and was eventually discharged to a skilled nursing facility. This case highlights a severe adverse reaction to an immunomodulator class steadily growing in its application. Providers of all specialties should be aware of the side effects and treatment options. Our case demonstrates that continued investigation into the utilisation of CTLA-4 agonists in the treatment of severe adverse reactions like myocarditis caused by pembrolizumab is required.

  • cancer – see Oncology
  • cancer intervention
  • immunology
  • skin cancer
  • unwanted effects / adverse reactions

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  • Contributors CW, who is guarantor, performed the literature review and patient communications. She was the main contributor to manuscript development, revision and subsequent submission. MM directly cared for the patient and initiated the project. He directly assisted with manuscript development and revision. BP directly cared for the patient and remains involved in her long-term follow-up care. He assisted with manuscript development and revision. CS directly cared for the patient during her admission and assisted in manuscript revision. A special thanks is extended to the patient for her willingness to share her experience, which was a crucial component in composing this case report.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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