Immune Checkpoint Inhibitor Induced Pericarditis and Encephalitis in a Patient Treated With Ipilimumab and Nivolumab for Metastatic Melanoma: A Case Report and Review of the Literature

Immune checkpoint inhibitors (ICIs) have dramatically improved outcomes in melanoma. Common ICI toxicities have become familiar to clinicians; however, rare delayed toxicities remain challenging given the paucity of data with such presentations. We present the unique case of a 61-year-old with metastatic melanoma with two rare, delayed ICI-induced toxicities. After resection of a large symptomatic parietal metastases, this patient received two doses of combination ipilimumab and nivolumab. Five weeks following his second dose, he developed ICI-induced pericarditis with associated pericardial effusion and early signs of tamponade. Corticosteroids were not administered due to a concurrent cerebral abscess. Administration of colchicine, ibuprofen, judicious monitoring, and cessation of immunotherapy led to the complete resolution of the effusion over several weeks. Seven months following his last dose of immunotherapy, the patient developed ICI-associated grade four autoimmune encephalitis, presenting as status epilepticus. High-dose steroid initiation led to rapid clinical improvement. The patient remains in near-complete response on imaging with no recurrence of pericardial effusion and partial resolution of neurological symptoms. ICI-induced pericardial disease and encephalitis carry substantial mortality rates and prompt diagnosis and management is critical. Clinicians must therefore remain vigilant for these rare toxicities regardless of duration of drug exposure or time since cessation of therapy.

Radical pericardiectomy for pericardial diseases

Pericarditis is the most common form of pericardial disease. Its exact incidence remains unknown, probably because many cases resolve without diagnosis. Indications for pericardiectomy from the standpoint of the cardiac surgeon are based mainly on the physiopathology of 2 different entities that can overlap: inflammatory or relapsing pericarditis and constrictive pericarditis. Surgical indications are not always straightforward. Patients with inflammatory or relapsing pericarditis may undergo radical pericardiectomy because they experience severe symptoms despite maximal medical treatment or have sequelae from the medical treatment. Pericardiectomy is the standard treatment in patients with chronic constrictive pericarditis and persistent symptoms who are in New York Heart Association functional class III or IV and a class I recommendation in the European Society of Cardiology/European Association of Cardio-Vascular Surgery guidelines. The goal of surgery is always complete removal of any site of inflammation through a radical pericardiectomy.

A CASE OF BUDD CHIARI SYNDROME IN 16 YEARS OLD MALE

Budd chiari syndrome is an uncommon disorder dened as hepatic vein outow tract obstruction, which is independent of the level and mechanism of obstruction( except pericardial disease and cardiac cirrhosis and sinusoidal obstruction syndrome)

Cardiac Magnetic Resonance in the assessment of pericardial abnormalities: a case series

Background Cardiac Magnetic Resonance (CMR) has a unique role in evaluating pericardial disease, permitting non-invasive tissue analysis and hemodynamic assessment. Case Summary In Case 1 of recurrent pericarditis, CMR confirmed reactivation of inflammation with late gadolinium enhancement (LGE) and native T1/T2 mapping techniques, prompting therapeutic changes. In constrictive pericarditis, CMR is the only modality capable of differentiating a subacute potentially reversible form (Case 2), from a chronic, burnt out irreversible phase characterized by constrictive physiology (Case 3). Discussion CMR is an effective tool to tailor individual therapy, particularly in cases of recurrent and constrictive pericarditis. LGE provides diagnostic and prognostic information, and multiparametric mapping has emerged as a promising tool with incremental diagnostic value.

Cardiovascular disease

This chapter describes the anaesthetic management of the patient with cardiovascular disease. The topics include ischaemic heart disease (including perioperative myocardial infarction and percutaneous coronary intervention), valvular heart disease (incuding prosthetic valves), congenital heart disease, cardiomyopathy, pericardial disease, the patient with a transplanted heart, narrow complex arrhythmias, broad complex arrhythmias and heart block. For each topic, pre-operative investigation and optimisation, treatment, and anaesthetic management are described including peri-operative management of pre-existing arrhythmias (such as atrial fibrillation), and the patient with an implanted pacemaker or defibrillator.

Cardiovascular medicine

Cardiology in resource-poor countries?, Cardiac arrest and advanced life support protocols?, Chest pain?, Shock?, Hypertension?, Angina?, Myocardial infarction?, Cardiac arrhythmias?, Syncope, Heart failure?, Rheumatic fever and rheumatic heart disease?, Infective endocarditis?, Pericardial disease?, Myocarditis, Cardiomyopathies?