Asymptomatic Myocarditis with Mild Cardiac Marker Elevation Following Nivolumab-Induced Myositis.

Although myocarditis following immune checkpoint inhibitor (ICI) therapy is rarely reported, it is considered clinically important because of its high mortality rate. Although various tests may be used for early diagnosis, abnormalities suggestive of myocarditis may not be detected. We report a case of ICI-induced myositis and concurrent asymptomatic myocarditis with mild cardiac marker elevation following nivolumab therapy in a 79-year-old man with metastatic gastric cancer. In this case, cardiac magnetic resonance imaging was useful for diagnosis. Treatment with oral prednisolone rapidly improved the patient's symptoms and creatine kinase levels. Follow-up examination revealed no flare-up of myositis and exacerbation of myocarditis. Since ICI-induced myositis is often complicated by myocarditis, this case report highlights the importance of detecting concurrent myocarditis in patients with ICI-induced myositis through intensive cardiac assessments to improve clinical outcomes.

Acute type B aortic dissection with multiple cholesterol embolism: an autopsy case report.

Background: Most cases of cholesterol embolism are known to be triggered by cardiac catheterization, cardiovascular surgery, anticoagulation, or fibrinolytic therapy; however, spontaneous cases after aortic dissection are rare. In this report, we describe a case of cholesterol embolism after type B aortic dissection, which rapidly developed into multiple organ failure and death. Case summary: A 65-year-old man with untreated hypertension was admitted to our hospital with sudden back pain and diagnosed with type B aortic dissection. The patient experienced a rapid progression of inflammation and developed respiratory and renal failure, despite computed tomography showing no obvious progression of dissection. We attributed them to a cytokine storm and acute respiratory distress syndrome, but steroid pulse therapy did not alleviate the symptoms. Finally, the patient died on Day 6 after admission, and an autopsy was performed, which revealed cholesterol crystal occlusions in the kidney, spleen, and the left lower leg. The lumen in the aorta is filled with atheroma and thrombus, and we suspect that aortic dissection triggered failure of the aortic plaques and released cholesterol crystals to distal arteries that led to cholesterol embolism. Discussion: We experienced a patient with a type B aortic dissection that led to cholesterol embolism and rapid progression of respiratory and renal failure, resulting in death. The aortic dissection combined with cholesterol embolism was considered to trigger the subsequent severe inflammation, leading to rapid respiratory and renal failure. Our case points to the possibility that cholesterol embolism can extensively escalate inflammation after aortic dissection.