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Improved outcomes with early immunosuppression in patients with immune-checkpoint inhibitor induced myasthenia gravis, myocarditis and myositis: a case series

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Abstract

Purpose

Myasthenia gravis (MG) is a rare but life-threatening complication of immune-checkpoint inhibitor (ICI) therapy and often co-presents with myositis and myocarditis. Previous case series of ICI-related MG have reported high mortality rates. We present a series of ten patients from a tertiary oncology centre outlining outcomes of an early multi-modal immunosuppression strategy.

Methods

We reviewed The Christie Hospital database of immunotherapy-related toxicity from 2017 to 2020. Symptom severity was assessed using the Myasthenia Gravis Foundation of America (MGFA) classification.

Results

Ten patients with ICI-related MG were identified. All patients presented following 1 (n = 4) or 2 (n = 6) cycles of ICI. Symptom progression was rapid with a median of 3 days from onset of symptoms to admission. Concomitant myositis and myocarditis were observed in nine patients. AChR or MuSK autoantibodies were positive in six patients. All patients received urgent treatment with intravenous methylprednisolone (IVMP) and eight received intravenous immunoglobulin (IVIG). A single patient died from myasthenia-related symptoms; the remaining 9 patients were successfully discharged.

Conclusion

In our cohort, we demonstrate good outcomes associated with early intensive immunosuppressive treatment with IVIG and IVMP. An agreed national treatment protocol or clinical discussion forum would be beneficial.

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Author information

Authors and Affiliations

  1. Department of Acute Medicine, The Christie NHS Foundation Trust, Wilmslow Road Manchester, Manchester, UK

    Jamie MJ Weaver, Tom Knight, Raj Khera, Paul Lorigan & Tim Cooksley

  2. University of Manchester, Manchester, UK

    Jamie MJ Weaver, Mehek Chaudhri, Paul Lorigan & Tim Cooksley

  3. Manchester centre for Clinical Neurosciences, Northern Care Alliance, Manchester, UK

    Katie Dodd, James B Lilleker & Mark Roberts

Authors
  1. Jamie MJ Weaver
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  2. Katie Dodd
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  3. Tom Knight
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  4. Mehek Chaudhri
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  5. Raj Khera
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  6. James B Lilleker
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  7. Mark Roberts
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  8. Paul Lorigan
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  9. Tim Cooksley
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Contributions

JW, JL, MR, PL and TC conceived the implementation of the project and wrote the main manuscript text and prepared the figures. TK, MC and RK collected data, assisted in manuscript and figure preparation. All authors reviewed the manuscript.

Corresponding author

Correspondence to Tim Cooksley.

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Ethics approval

This is an observational study with no ethical approval required. Local institutional board number: 3180.

Competing interests

The authors declare no competing interests.

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Weaver, J.M., Dodd, K., Knight, T. et al. Improved outcomes with early immunosuppression in patients with immune-checkpoint inhibitor induced myasthenia gravis, myocarditis and myositis: a case series. Support Care Cancer 31, 518 (2023). https://doi.org/10.1007/s00520-023-07987-x

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  • DOI: https://doi.org/10.1007/s00520-023-07987-x

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