We report a case of
myasthenia gravis,
myocarditis, and
myositis following the treatment of
melanoma with
nivolumab. The patient was a 68-year-old Caucasian male with stage 3
melanoma status after two doses of
nivolumab with
shortness of breath, intermittent palpitations,
dizziness, and
nausea. During his initial evaluation, he was found to have
atrial fibrillation with rapid ventricular response along with new-onset proximal
muscle weakness,
double vision,
dysphagia, and ptosis of the right eye. Further diagnostic workup of the
pleural effusion with CT of the chest showed large right
pleural effusion with adjacent
atelectasis. Thoracentesis was completed without complications and resulted in an exudative effusion with negative cytology and cultures. Serologic studies showed elevated
troponin and serum
creatine kinase, negative
acetylcholine receptor antibody, and negative modulating antibody. Despite negative antibody tests, the patient's symptoms suggested a clinical diagnosis of
myasthenia gravis. The
ice pack test was performed, which showed temporary improvement of the patient's ptosis. Given the suspicion for
myasthenia gravis and positive
ice pack test, he was treated with
corticosteroids,
intravenous immunoglobulin (
IVIG), and
pyridostigmine. He completed a total of three doses of
IVIG with improvement in
diplopia. Despite
steroids and respiratory support with
BiPAP (bilevel positive airway pressure), on the 14th day of hospitalization, the patient had
multiple organ failure along with worsening
respiratory failure. The patient discussed the situation with his family, and they decided on
hospice care. The patient was discharged to hospice on admission day 14.