Dr. United Medical and Dental College (UMDC), Sindh, Pakistan
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Introduction: Immune checkpoint inhibitors (ICIs) like pembrolizumab have improved prognosis of patients with cancer. However, ICIs are associated with variety of side effects known as immune-related adverse events (irAEs) including pneumonitis and myocarditis. Treatment for irAEs involves holding the offending agent and in most cases involve initiation of corticosteroids, which also carry adverse side effects like psychosis. We present a case of steroid induced psychosis with hospital course complicated by acute ST-elevations on EKG. Clinical dilemma of this case involves determining myocarditis versus Takotsubo cardiomyopathy.
Description: A 67-year-old female with metastatic non-small cell lung cancer on pembrolizumab was admitted for acute psychosis following initiation of high-dose corticosteroids for grade 3 pneumonitis. During hospitalization, patient required doses of olanzapine for severe agitation. Therefore, a routine EKG was conducted which demonstrated acute STEMI. She was urgently taken for cardiac catheterization with no signs of acute ischemic changes. Echocardiography post catheterization, however, showed apical ballooning with reduced ejection fraction consistent with Takotsubo cardiomyopathy. Cardiac MRI was also conducted to rule out myocarditis in the setting of ICI, MRI revealed some myocardial edema suggestive of myocarditis. Though the clinical diagnosis was confounding with two different findings, her acute decompensation was clinically attributed to stress-induced cardiomyopathy. The patient was managed with supportive care and beta-blockers. Repeat echocardiogram four days later demonstrated normalization of ejection fraction.
Discussion: This case highlights the clinical dilemma with overlapping irAEs and severe psychosis resulting in Takotsubo cardiomyopathy. Despite cardiac MRI findings suggesting inflammatory changes consistent with myocarditis, the acute decompensation was related to Takotsubo due to absence of significant hemodynamic instability and rapid recovery of heart function. The inflammatory changes noted on MRI were attributed to prior irAE rather than new changes. This case highlights the importance of understanding clinical complexities in oncological patients and recognizing adverse effects of ICIs and steroids.
