Recovery from fulminant immune-related myocarditis induced by ipilimumab plus nivolumab in malignant pleural mesothelioma: a case report

Immune checkpoint inhibitors (ICIs) have become standard therapies for various cancers; however, their use can lead to diverse immune-related adverse events (irAEs). While most irAEs are mild, some, such as myocarditis, although rare, have a high mortality rate. This report highlights a case in which aggressive and invasive therapeutic interventions led to successful patient survival after fulminant ICI-induced myocarditis. A 64-year-old male with a malignant pleural mesothelioma was admitted to the hospital with dyspnea on day 22 after the first cycle of ipilimumab plus nivolumab. Upon admission, he presented with cardiogenic shock and pulseless ventricular tachycardia, accompanied by elevated cardiac biomarkers. Owing to a history of ICI treatment, immune-related myocarditis was suspected, and high-dose methylprednisolone was immediately initiated. As his hemodynamic status rapidly deteriorated, extracorporeal membrane oxygenation (VA-ECMO), percutaneous left ventricular assist device (pLVAD), and temporary transvenous cardiac pacing were promptly initiated to stabilize the circulation. A myocardial biopsy confirmed lymphocytic myocarditis. The patient gradually stabilized and was successfully weaned off aggressive circulatory support, leading to patient’s discharge on day 69. Early methylprednisolone pulse therapy is crucial in treating immune-related myocarditis. To bridge the time until the steroids become fully effective, aggressive interventions such as VA-ECMO, pLVAD, and external pacing can play a life-saving supportive role. This underscores the importance of close collaboration with cardiologists to promptly implement these bridging therapies, which are vital for patient survival.