Recovery from fulminant immune-related myocarditis induced by ipilimumab plus nivolumab in malignant pleural mesothelioma: a case report

Our plain-English summary of Recovery from fulminant immune-related myocarditis induced by ipilimumab plus nivolumab in malignant pleural mesothelioma: a case report, by Y. Konya, J. Tanizaki, K. Onishi, et al (BMC Pulmonary Medicine, 2026).

The study

• Authors: Y. Konya, J. Tanizaki, K. Onishi, H. Matsuzoe, H. Kanemura, T. Takahama, K. Tanaka, G. Nakazawa, H. Hayashi
• Journal: BMC Pulmonary Medicine
• Published: 2026;26(1)
• Type of article: Case report
• Read it: PubMed · Publisher · Free full text

Abstract

BACKGROUND: Immune checkpoint inhibitors (ICIs) have become standard therapies for various cancers; however, their use can lead to diverse immune-related adverse events (irAEs). While most irAEs are mild, some, such as myocarditis, although rare, have a high mortality rate. This report highlights a case in which aggressive and invasive therapeutic interventions led to successful patient survival after fulminant ICI-induced myocarditis. CASE PRESENTATION: A 64-year-old male with a malignant pleural mesothelioma was admitted to the hospital with dyspnea on day 22 after the first cycle of ipilimumab plus nivolumab. Upon admission, he presented with cardiogenic shock and pulseless ventricular tachycardia, accompanied by elevated cardiac biomarkers. Owing to a history of ICI treatment, immune-related myocarditis was suspected, and high-dose methylprednisolone was immediately initiated. As his hemodynamic status rapidly deteriorated, extracorporeal membrane oxygenation (VA-ECMO), percutaneous left ventricular assist device (pLVAD), and temporary transvenous cardiac pacing were promptly initiated to stabilize the circulation. A myocardial biopsy confirmed lymphocytic myocarditis. The patient gradually stabilized and was successfully weaned off aggressive circulatory support, leading to patient’s discharge on day 69. CONCLUSIONS: Early methylprednisolone pulse therapy is crucial in treating immune-related myocarditis. To bridge the time until the steroids become fully effective, aggressive interventions such as VA-ECMO, pLVAD, and external pacing can play a life-saving supportive role. This underscores the importance of close collaboration with cardiologists to promptly implement these bridging therapies, which are vital for patient survival.

In plain English

This case report from Kindai University, Japan, described a 64-year-old man with epithelial-type malignant pleural mesothelioma and a history of asbestos exposure and smoking. In May 2024 he began nivolumab plus ipilimumab immunotherapy. On day 22 of the first cycle he became short of breath. He reached the emergency department with blood pressure too low to measure and pulseless ventricular tachycardia, a dangerous heart rhythm. Doctors suspected immune-related myocarditis, an inflammation of the heart muscle triggered by the drugs. They gave high-dose methylprednisolone, a steroid, within about 6 hours of symptom onset. Within hours he worsened, and his left ventricular ejection fraction fell to 22%. He was supported with VA-ECMO (a heart-lung machine), a percutaneous heart pump and temporary pacing. A heart biopsy showed lymphocytic myocarditis. All three devices were removed by hospital day 11. His ejection fraction recovered to 68%, and he was discharged on day 69. The authors concluded that early high-dose steroids combined with aggressive mechanical circulatory support enabled this patient's survival, and that close coordination between cancer and heart teams is crucial.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (one patient)
• Who was studied: One 64-year-old man with epithelial-type malignant pleural mesothelioma (Stage IV), a smoking history and asbestos exposure, treated at Kindai University Faculty of Medicine, Japan, starting May 2024
• Exposure: Immune checkpoint inhibitor therapy: nivolumab 360 mg every 3 weeks plus ipilimumab 1 mg/kg every 6 weeks. Asbestos exposure was mentioned as part of the patient's history, with no fiber type or other details given.
• Main results:
  • The patient developed shortness of breath on day 22 of the first treatment cycle.
  • On arrival, the ECG showed pulseless ventricular tachycardia.
  • High-dose methylprednisolone (1000 mg for three days) was given on the day of admission without waiting for biopsy results, within 6 hours of symptom onset.
  • Within a few hours of starting steroids, left ventricular ejection fraction fell to 22%, with biventricular failure.
  • Mechanical circulatory support was started: VA-ECMO, a percutaneous left ventricular assist device (Impella CP), and external pacing.
  • VA-ECMO was discontinued on hospital day 6.
  • The pLVAD was removed on hospital day 10.
  • Left ventricular ejection fraction recovered from 22% to 68%.
  • Temporary transvenous pacing was withdrawn on hospital day 11.
  • Immunohistochemical staining of the endomyocardial biopsy was positive for CD4, CD8 and CD68, consistent with lymphocytic myocarditis.
  • Of the cytokines measured, only IL-6 showed mild fluctuations: 83.1 pg/mL before symptom onset, 118 pg/mL in the emergency department, and 37.4 pg/mL after steroids were started.
  • The patient was kept on a 5 mg maintenance oral steroid dose.
  • The patient was discharged on day 69.
• The authors' conclusion: The authors concluded that early high-dose steroid therapy, given within about six hours of symptom onset and combined with aggressive mechanical circulatory support, enabled this patient to survive fulminant ipilimumab plus nivolumab induced myocarditis. They added that rapid, close coordination between the oncology and cardiology teams is crucial.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Ipilimumab (Yervoy), Nivolumab (Opdivo), Pleural Mesothelioma, checkpoint inhibitors, Immune-Related Adverse Events, Dyspnea, Biomarker, Biopsy.

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