Cutaneous melanoma, pT3b, St. IV (AJCC 2017)
01/2015 nodular melanoma of the back, BRAF wildtype, Breslow 2,9 mm
10/2019 pulmonal metastases
01/2020 cerebral metastases
Immunotherapy with ipilimumab / nivolumab (1 cycle)
Four weaks after initiation of the immunotherapy (IT) the patient presented with uncertain gait, proximal muscle weakness, double vision and shortness of breath. Laboratory results showed a significant increase of serum creatine kinase (CK, 1800 U/l), elevated CK-MB (10,4 fold increase) and Troponin-I (634 pg/ml) levels thus confirming irMyositis with ocular involvement. To rule out myocarditis further diagnostic procedures were undertaken. A cardiac MRI showed an apical hypokinesia and a myokardial biopsy showed a lymphocytic myocarditis. Diagnosis of a CTCAE grade 3 irMyositis and irMyocarditis was confirmed.
High-dose systemic corticosteroid therapy was initiated (1 g per day over three daysand 1mg/kg per day thereafter which led to clinical improvement. Therapy was tapered over 4 weeks.
Immunotherapy was interrupted. Subsequent therapy due to progressive disease was initiated with Temozolomid.
Checkpoint Inhibitor-induced Myositis (irMyositis) is accompanied by the involvement of the myocard in up to 32% of cases (Moreira A et al. Eur J Cancer. 2019.). It is life-threatening giving rise to cardiac arrhythmias and/or a reduced left ventricular ejection fraction and has a high fatality rate (Wang et al. JAMA Oncol. 2018). Ophthalmoplegia can be a manifestation of ocular myositis, representing a frequent manifestation of irMyositis (Garibaldi M et al. Neuromuscul Disord. 2020). It can occur isolated or combined with shoulder girdle manifestation, as shown in our patient. Clinicians should be aware of manifestations of irMyositis and monitor serum creatine kinase as well as clinical symptoms. If diagnosed immediate treatment with corticosteroids is necessary to improve outcome.
