DOI: 10.1161/circ.148.suppl_1.15265 ISSN: 0009-7322

Abstract 15265: Rilonacept for Refractory Pericarditis Following Immune Checkpoint Inhibitor Therapy: A Case Report

Mohanad Hamandi, Janelle Gooch, Joshua E Levenson
  • Physiology (medical)
  • Cardiology and Cardiovascular Medicine

Background: Immune checkpoint inhibitor (ICI)-mediated cardiotoxicities are rare but potentially fatal. Myocarditis, with clinical presentations ranging from asymptomatic to cardiogenic shock, and pericarditis, have been reported in clinical trials and as post-marketing experience with immunotherapy. It is estimated to occur in less than 1% of individuals receiving single immune checkpoint inhibitor therapy, with a median time to onset of 30 days. Herein, we report a case of late-onset ICI-mediated myopericarditis presenting with cardiogenic shock, followed by recurrent pericarditis refractory to steroid taper.

Case Presentation: A 44-year-old woman with triple-negative breast cancer underwent chemotherapy, immune checkpoint inhibitor therapy with Pembrolizumab, lumpectomy, and radiation therapy. After the treatment, the patient developed symptoms consistent with myopericarditis, complicated by pericardial effusion with tamponade and cardiogenic shock. The patient underwent emergent pericardiocentesis and, due to refractory shock, was initiated on high-dose steroid therapy with complete resolution. However, during the tapering of steroids, the patient experienced a recurrence of pericarditis, characterized by chest pain, recurrent pericardial effusion, and elevated inflammatory markers. NSAIDs and colchicine were initiated early in the management but failed to achieve symptom control. Given the refractory nature of the recurrent pericarditis, the decision was made to reintroduce prednisone therapy, which led to substantial symptomatic improvement. To avoid further flares with steroid taper, the patient was started on rilonacept. It led to sustained pain control, and steroids were successfully tapered.

Conclusion: Pericarditis is a rare complication of pembrolizumab. There are no specific guidelines on the management of ICI-related recurrent pericarditis. Rilonacept was added due to the refractory nature of her symptoms with steroid taper. It led to sustained improvement in pain, and steroids were successfully tapered.

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