A 67-year-old male patient was admitted to the hospital with new onset fever, chest pain and dyspnea for 7 days and previous diagnose of right lung squamous cell carcinoma. His previous medical history was notable for right lung squamous cell carcinoma stage IV (T3N3M1) complicated with mediastinal lymph nodes and liver metastasis 1 year before. Cardiac and pulmonary function was normal at that time. Four cycles of chemotherapy with paclitaxel-cisplatin regimen was initiated but afterwards stopped due to 2019 coronavirus outbreak. Ten months thereafter, he was admitted to the hospital because of right massive pleural effusion. Twice bacterial culture of pleural effusion displayed Prevotella nigrescens, indicating right lung squamous cell carcinoma complicated with empyema. With subsequent treatment of meropenem as the anti-bacterial agent, his symptoms were relieved and his temperature was normal. As a result, chemotherapy was discontinued and replaced with PD-L1 immune checkpoint inhibitor, durvalumab monotherapy for four cycles (500 mg intravenous drip). And he presented with the symptom of fever, chest pain and dyspnea 7 days after last cycle of durvalumab. Moreover, the previous medical, family, and psychosocial history as well as genetic information showed nothing special.
Physical and laboratory examination was done for the patients upon this admission. The highest temperature was 39.4 C. His blood pressure was 121/69 mmHg. Chest computed tomography (CT) examination indicated right bronchial obstruction, obstructive pneumonia and right pleural effusion (Figure 1A). Echocardiography revealed ventricle size within normal range (left ventricle end diastolic dimension 46 mm), increased atrium size (left atrium dimension LA 36 mm) and markedly decrease cardiac ejection fraction (left ventricular ejection fraction 41%), tracing 2 mm pericardial effusion (Figure 1B). The electrocardiogram showed sinus tachycardia, low voltage of limb leads, T wave inversion in anterior waves and V1-V3 QS type (Figure 1C). Markers of myocardial injury were elevated: Natriuretic peptide BNP 18 942 ng/L; Troponin T 0.066 ng/L; Troponin I 200.83 ng/L; Creatine kinase (CK) and Creatine kinase isoenzyme (CKMB) normal. Moreover, inflammatory indicators were significantly elevated. Erythrocyte sedimentation rate (ESR) was markedly increased with the level of 101 mm/h, and C-reactive protein (CRP) 268.2 mg/L. Interleukin-6 was 44.93 pg/mL.
Judging by the decreased cardiac function and elevated myocardial injury markers at this admission, the patient was diagnosed of acute immune-associated myocarditis and right lung squamous cell carcinoma complicated with empyema. Treatments included methylprednisolone to suppress inflammation (40 mg, once per day, iv), meropenem to control infection (1.0 g, q8h, iv.drip) and symptomatic and supportive treatments. Seven days after admission, the patient's symptoms were relieved. Myocardial injury and inflammation markers were significantly decreased: Natriuretic peptide BNP was down to 2,298 ng/L; Troponin T, Troponin I, CK and CKMB normal; ESR 41 mm/h; CRP 29.8 mg/L; and Interleukin-6 normal. The electrocardiogram showed normal sinus rate and V2-V5 T wave inversion (Figure 1C). Echocardiography revealed ventricle size within normal range (left ventricle end diastolic dimension 48 mm), increased atrium size (left atrium dimension LA 30 mm) and markedly recovered cardiac ejection fraction (left ventricular ejection fraction 66%). The patient was discharged with prescription of continuing oral methylprednisolone (20 mg, once per day, po) and anti-bacterial therapy of faroenem to control infection (150 mg, q8h, po). No further heart failure exacerbations have occurred to date.