Antineoplastics

Abstract

Various toxicities: case report A 67-year-old man developed multiorgan failure, fulminant myocarditis, myasthenia gravis crisis, hepatic dysfunction, ptosis, myopathy and delayed pneumonitis during treatment with carboplatin, pembrolizumab and pemetrexed for large-cell neuroendocrine carcinomas [routes not stated]. The man presented with dyspnoea on exertion, ptosis, blurred vision and quadriparesis. His medical history was significant for T4N2M1c lung large-cell neuroendocrine carcinomas and bone metastasis. Two weeks prior to the presentation (in May 2019), he started receiving pembrolizumab 200mg, pemetrexed 900mg and carboplatin 400mg. On presentation, his laboratory test showed elevated creatine phosphokinase (4256 U/L), creatine kinase MB isoenzyme (109 U/L), brain natriuretic peptide (6390 pg/mL), troponin-I (9.34 ng/mL), myohemoglobin (1943.7 pg/mL). His liver function tests showed elevated AST (661 U/L) and ALT (212 U/L). Subsequently, his electrocardiogram revealed a complete left heart block. From the above findings, he was diagnosed with simultaneous multiorgan failure, myocarditis, myasthenia gravis crisis, hepatic dysfunction and ptosis. Therefore, the man started receiving treatment with methylprednisolone. However, his arrhythmia did not improve significantly. Therefore, the temporary pacemaker was implanted, and treatment with methylprednisolone continued. Subsequently, his creatine phosphokinase, brain natriuretic peptide and troponin-I gradually improved. Due to his condition, the temporary pacemaker was replaced with a permanent pacemaker. Thereafter, he underwent muscle biopsy, which showed partial myofibril cavity degeneration, myolysis, and most of the striated interstitium showed focal lymphocyte infiltration, which was consistent with druginduced myopathy. Thereafter, on 43 days of hospitalisation, his heart failure symptoms improved, and he discharged was from the hospital. However, 2 weeks later he again presented to the hospital due to dyspnoea on exertion. In this presentation, his vital signs were as follows: BP 140/85 mmHg, body temperature 36.5°C, HR 110 bpm and oxygen saturation was 92%. Subsequently, his chest X-ray and CT scan showed a percolate increasing in the lung. Therefore, he received treatment with ganciclovir and cefmetazole for 7 days. However, his dyspnoea did not improve. Repeated chest, X-ray and CT scan showed an increase in percolate. Therefore, he was diagnosed with delayed pneumonitis. Therefore, he received treatment with methylprednisolone, along with ganciclovir and cefmetazole. Following 3 days of treatment, his symptoms significantly improved. On follow up 3 months later, his symptoms did not reoccur.