Description:
<jats:p>A 49-year-old female patient was admitted with symptoms of septic shock after her 8th cycle of neoadjuvant Carboplatin + Paclitaxel plus her 3rd cycle of Pembrolizumab for triple negative breast cancer in a curative setting. Despite empiric antibiotic therapy and fluid substitution the patient’s status continuously worsened necessitating a brief transfer to an ICU unit with catecholamine support. Levels of NT-proBNP (581pg/mL) and Troponin T (41ng/L) were measured on admission and massively increased to NT-proBNP 8038pg/mL and Troponin T 1044ng/L on the 2nd day. Sinus tachycardia, hypotension and lower extremity edema were apparent as signs of decompensated heart failure. Echocardiography showed moderate pericardial effusion, with preserved LV function and lack of wall motion abnormalities. Immune-checkpoint inhibitor (ICI) induced myocarditis was suspected. An MRI showed subendocardial late gadolinium enhancement (LGE) in the apex and midventricular wall, which was interpreted as either representing ischemic infarction or atypically distributed LGE due to ICI-associated myocarditis. An LVEF of 40%, as well as apical akinesia in the apex and midventricular sections consistent with apical ballooning as in Tako Tsubo syndrome were also observed. Angiography showed lesions consistent with spontaneous coronary artery dissection (SCAD) in the LAD and RCA. No PCI was performed. Over the next 2 weeks NT-proBNP and Troponin T continued to decline until discharge, and the patient stabilized with preserved ejection fraction. To summarize, this is a case of ICI myocarditis with concurrent SCAD and takotsubo-like left ventricular dysfunction.</jats:p>
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