Case ReportEosinophilic Myocarditis in a Patient With Multiple Myeloma
Introduction
Eosinophilic myocarditis (EM) is a rare condition characterized by inflammation of the myocardium and eosinophilic infiltration.1 The clinical presentation varies from chronic restrictive cardiomyopathy to acute fulminant myocarditis.1,2 The pathophysiology underlying this condition is not completely understood, but eosinophils play a major role in releasing reactive substances, which directly damage myocytes and endothelial cells such as major basic proteins, cationic proteins, and reactive oxygen agents.2 Eosinophilic myocarditis has been associated with vasculitides, hypereosinophilic syndrome, and certain drugs.1 Lenalidomide is an immunomodulatory drug structurally related to thalidomide, but with higher potency. It is used in the up-front or relapse setting for multiple myeloma (MM).3 Cardiotoxicity with its use has been documented, including increased risk of arrhythmias (bradycardia and atrial fibrillation), thromboembolism, and angina.3 Another commonly used treatment for MM is bortezomib, which targets the ubiquitin–proteasome system in plasma cells, and which has been implicated in the onset of cardiomyopathies and atherosclerosis4,5 Lenalidomide and bortezomib are both radiosensitizers,6,7 and EM has been reported after lenalidomide therapy.8
We report a case of EM in a woman who received the combination of radiotherapy and lenalidomide for MM treatment.
Section snippets
Case Report
A 59-year-old woman was diagnosed with stage II IgA kappa MM after a pathologic fracture of the sixth thoracic vertebrae. Diagnosis was done according to the Revised International Staging System for Multiple Myeloma. She received radiotherapy for a total of 36 Gy over 28 days. Ten days before culmination of radiotherapy, she initiated therapy with lenalidomide 25 mg provided orally on days 1 to 14, bortezomib 1.3 mg/m2 provided subcutaneously on days 1, 4, 8, 11, and dexamethasone 20 mg
Discussion
Data are limited regarding the cardiac effects of using the combination of radiotherapy and lenalidomide for MM treatment. However, given the radiosensitizer’s dose-limiting pulmonary toxicity (eosinophilic pneumonitis) of lenalidomide, study of cardiac toxicity and caution with concurrent use are warranted.7,9 The diagnosis of EM requires a high level of suspicion and liberal use of available tests, including cardiac enzymes and advanced imaging studies such as contrast-enhanced cardiac
Conclusion
Cardiologic evaluation and endomyocardial biopsy should be considered to confirm the diagnosis of EM.10 A treatment algorithm for EM has not yet been established, but discontinuation of the offending drug, prompt delivery of corticosteroid therapy, and pharmacologic management of heart failure are recommended for this exceptionally rare and potentially fatal disease.8,11
Disclosure
The authors have stated that they have no conflict of interest.
References (11)
- et al.
Eosinophilic myocarditis: characteristics, treatment, and outcomes
J Am Coll Cardiol
(2017) - et al.
A pilot safety study of lenalidomide and radiotherapy for patients with newly diagnosed glioblastoma multiforme
Int J Radiat Oncol Biol Phys
(2009) - et al.
Fulminant versus acute nonfulminant myocarditis in patients with left ventricular systolic dysfunction
J Am Coll Cardiol
(2019) - et al.
From multiple myeloma to myocarditis
J Am Coll Cardiol
(2019) - et al.
The clinicopathological profile of eosinophilic myocarditis
Cureus
(2018)
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