Immune checkpoint-mediated myositis and myasthenia gravis: A case report and review of evaluation and management

Kylie H Kang; William Grubb; Komal Sawlani; Michael K Gibson; Christopher J Hoimes; Lisa R Rogers; Pierre Lavertu; Min Yao

doi:10.1016/j.amjoto.2018.06.003

Immune checkpoint-mediated myositis and myasthenia gravis: A case report and review of evaluation and management

Am J Otolaryngol. 2018 Sep-Oct;39(5):642-645. doi: 10.1016/j.amjoto.2018.06.003. Epub 2018 Jun 5.

Authors

Kylie H Kang¹, William Grubb², Komal Sawlani³, Michael K Gibson⁴, Christopher J Hoimes⁵, Lisa R Rogers³, Pierre Lavertu⁶, Min Yao⁷

Affiliations

¹ Case Western Reserve University School of Medicine, Cleveland, OH, USA; Department of Radiation Oncology, University Hospitals Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA. Electronic address: kylie.kang@case.edu.
² Department of Radiation Oncology, University Hospitals Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
³ Case Western Reserve University School of Medicine, Cleveland, OH, USA; Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
⁴ Division of Hematology and Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA.
⁵ Case Western Reserve University School of Medicine, Cleveland, OH, USA; Division of Hematology and Oncology, Case Comprehensive Cancer Center at University Hospitals Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
⁶ Case Western Reserve University School of Medicine, Cleveland, OH, USA; Department of Otolaryngology - Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
⁷ Case Western Reserve University School of Medicine, Cleveland, OH, USA; Department of Radiation Oncology, University Hospitals Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.

PMID: 29903623
DOI: 10.1016/j.amjoto.2018.06.003

Abstract

Background: We present a case of myositis and possible overlapping neuromuscular junction disorder following treatment with nivolumab for recurrent/metastatic head and neck squamous cell carcinoma (HNSCC).

Methods: We report a 75-year-old man with recurrent stage IVA, T1N2cM0 oral cavity HNSCC treated with weight-dosed nivolumab who presented three weeks later with severe fatigue, generalized weakness, and bilateral ptosis. Evaluation demonstrated elevated creatine kinase and myopathic motor units on electromyography, supporting a diagnosis of an underlying muscle disease. Elevated serum acetylcholine receptor binding antibodies raised the possibility of concurrent myasthenia gravis.

Results: He received corticosteroids and plasmapheresis without improvement in muscle weakness. His course was complicated by bacteremia, cardiac arrest, and concerns for recurrent malignancy. Following a two-month hospital stay, he was made comfort care and died.

Conclusions: With increasing usage of checkpoint inhibitors in HNSCC, clinicians must be aware of and vigilant for associated rare but serious adverse events.

Keywords: Head and neck cancer; Immune checkpoint inhibitor; Immune-related adverse event; Myositis; PD-1.

Publication types

Case Reports
Review

MeSH terms

Aged
Antineoplastic Agents, Immunological / adverse effects*
Head and Neck Neoplasms / drug therapy*
Humans
Male
Myasthenia Gravis / chemically induced*
Myasthenia Gravis / diagnosis
Myasthenia Gravis / therapy
Myositis / chemically induced*
Myositis / diagnosis
Myositis / therapy
Nivolumab / adverse effects*
Squamous Cell Carcinoma of Head and Neck / drug therapy*

Substances

Antineoplastic Agents, Immunological
Nivolumab