Lung cancer immunotherapy causing sudden heart inflammation and type 1 diabetes

What happened, in summary

A woman in her mid-60s had Stage IIIB poorly differentiated lung adenocarcinoma, cT3N2M0. Her treatment included carboplatin with nab-paclitaxel and radiation, followed by carboplatin with pemetrexed. She then began consolidation durvalumab.

Four weeks after the first durvalumab dose, she came to hospital with nausea, vomiting, profound weakness, shortness of breath, and frequent urination. Testing showed diabetic ketoacidosis caused by sudden-onset type 1 diabetes. At the same time, she developed abnormal heart rhythms and inflammation of the heart muscle. The combination was considered a severe immune-related reaction to durvalumab.

She was treated in intensive care. Insulin corrected the diabetic ketoacidosis and became necessary for ongoing diabetes management. Temporary cardiac pacing was used for the rhythm problem. She received IV methylprednisolone 1,000 mg daily for 3 days, followed by a prednisone taper lasting about 14 weeks.

She left hospital after 6 days once the acute symptoms had settled. One month later, cardiac MRI showed that her heart’s pumping function had returned to her previous baseline ejection fraction of 32%. Because both the myocarditis and fulminant diabetes were life-threatening, durvalumab was permanently stopped. Continued follow-up involved oncology, endocrinology, and cardio-oncology. Her later lung-cancer response was not yet established.

She had pre-existing reduced heart function, which made the new myocarditis especially dangerous. The simultaneous onset of diabetes and heart inflammation showed that immune treatment can affect more than 1 organ at once. She required ongoing insulin after the sudden onset of type 1 diabetes. Durvalumab was never restarted.