A 43-year-old woman with a history of recently diagnosed metastatic melanoma was commenced on systemic therapy with nivolumab, an anti-programmed cell death-1 monoclonal antibody and one of an increasing group of the so-called ‘immune checkpoint inhibitors’. She experienced a dramatic complete response within 6 months of initiation. However, in addition to developing incident autoimmune hypothyroidism, she also developed progressive fatigue, proximal weakness, myalgia and dysphagia. Initial investigations with blood tests, electrophysiology and a muscle biopsy were non-specific or normal. Subsequent examination revealed ‘woody’ thickening of the subcutaneous tissues of the forearms, thighs and calves consistent with fasciitis. MRI and a full-thickness skin–muscle biopsy were ultimately diagnostic of a likely iatrogenic autoimmune myofasciitis. The clinical manifestations only responded partly to prednisolone 30 mg orally and treatment was escalated to include intravenous immunoglobulin. At 3 months, this has only resulted in a modest incremental improvement.
- musculoskeletal and joint disorders
- muscle disease
- unwanted effects / adverse reactions
- musculoskeletal syndromes
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Contributors MJSP was involved in the conception and design, acquisition of data, drafting the article and final approval of the version published. MER, PCL, DGdP and HC were involved in the conception and design, revising the manuscript critically and in the final approval of the version published.
Funding PCL received research funding from Bristol-Myers Squibb
Competing interests PCL has acted as a paid consultant and has received support for travel from Bristol-Myers Squibb.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
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