Immune Checkpoint Inhibitor-Associated Myocarditis With Persistent Troponin Elevation Despite Abatacept and Prolonged Immunosuppression
Bibliographic record
Abstract
A 78-year-old woman with hypertension, type 2 diabetes mellitus, and hyperlipidemia was diagnosed with stage 3C, BRAF wild-type left knee melanoma.Following local excision and sentinel lymph node surgery, she received adjuvant pembrolizumab (2 mg/kg every 3 weeks), a monoclonal antibody against the programmed cell death receptor-1 (PD-1).Two weeks after the second pembrolizumab dose, she presented to the emergency department with a 5-day history of exertional dyspnea and dysphagia.Cardiovascular examination revealed an irregular heart rate (105 to 140 beats/min) and signs of heart failure (HF).Neurological examination demonstrated bilateral asymmetric ptosis with fatigability and proximal muscle weakness.High-sensitivity troponin T (3,075 ng/l, 99th percentile <15 ng/l, Roche Diagnostics, Indianapolis, Indiana), Nterminal pro-B-type natriuretic peptide (4,246 pg/ml, reference range [RR] <300 pg/ml for age >75 years, Roche Diagnostics, Basel, Switzerland), and creatine kinase (2,487 U/l, RR <149 U/l, Abbott Diagnostics, Abbott Park, Illinois) were markedly elevated.Electrocardiogram showed atrial tachycardia with new right bundle branch and left anterior fascicular block.Transthoracic echocardiogram revealed a left ventricular ejection fraction (LVEF) of 65% with hypokinesis of the basal-to-mid-inferior wall and basal inferoseptum.Initial cardiovascular magnetic resonance (CMR) imaging was nondiagnostic due to patient noncompliance.Coronary angiography showed no flow-limiting disease.Single-fiber electromyography of the frontalis muscle revealed abnormalities compatible with myasthenia gravis (MG); acetylcholine receptor antibody (AchR-Ab) was negative.She was diagnosed with immune-related adverse events related to immune checkpoint inhibitor (ICI) including myocarditis based on the European Society of Cardiology (ESC) criteria (1) and neuromuscular complications.She was started on intravenous methylprednisolone (1,000 mg twice daily).On day 2 of admission, she developed monomorphic ventricular tachycardia and received intravenous amiodarone.Later in the day, she developed high-grade atrioventricular block and R-on-T polymorphic ventricular tachycardia requiring resuscitation with 4 shocks and a temporary pacemaker.She stabilized with intravenous methylprednisolone (1,000 mg once daily); however, switching to oral prednisone resulted in a recurrent rise in
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.001 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.002 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.001 | 0.000 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.002 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".