免疫检查点抑制剂相关心肌炎临床诊疗实施建议

免疫检查点抑制剂（immune-checkpoint inhibitors，ICIs）现已应用于多种恶性肿瘤的治疗，为肿瘤患者带来获益的同时，其严重ICIs相关心肌炎日益为临床带来新挑战。本临床诊疗实施建议聚焦ICIs相关心肌炎的危险因素、诊断与鉴别诊断、临床分型及治疗、监测转归和治疗重启等关键临床问题，参考国内外相关共识或指南和新近发表的循证证据，结合实际临床经验，为ICIs相关心肌炎的诊疗提供具有实践性的指导意见和建议。     

爆发性心肌炎的诊治进展

<正>爆发性心肌炎(fulminant myocarditis)起病急骤、病情发展迅猛[1]、预后凶险,且早期症状常不典型,易误诊。患者常存在严重的血流动力学障碍,并且临床表现多样,无特异性的实验室指标,早期的基于生命支持的综合治疗可显著提高患者的存活率。1 爆发性心肌炎1.1 流行病学特征爆发性心肌炎,又称急性重症病毒性心肌炎,是一种临床综合征。它不是基于病因的诊断,而是寻找各种病因的临床综合征,它可以被认为是急性心肌炎的一部分     

免疫检查点抑制剂治疗的肝脏毒性管理

免疫检查点抑制剂（immune checkpoint inhibitors，ICIs）在肿瘤领域取得了令人瞩目的疗效，使肿瘤治疗进入免疫治疗的新时代。但随着ICIs的广泛使用，免疫相关不良事件（immune-related adverse events，irAEs）也随之而来。肝脏是人体重要的代谢和消化器官，ICIs引起的肝脏不良事件应引起临床医师的关注。早发现、早诊断、规范治疗是改善预后的关键。本文简述irAEs的发病现状和可能机制，对现有的免疫相关肝脏毒性管理进行总结。     

小儿暴发型心肌炎32例临床分析

小儿病毒性心肌炎近年来已成为危害儿童健康的常见病、多发病，特别是暴发型心肌炎，起病急，进展快，首发症状多样。诊治不及时，可数小时或数日内死亡，少数可遗留左室功能障碍或过渡到扩张型心肌病。作者对2000-2004年收住我科的32例暴发型心肌炎临床资料进行总结，以期引起临床医师的重视，有助早期诊断与治疗，现报告如下。     

免疫检查点抑制剂的抗肿瘤临床实践与展望

基于靶向免疫检查点抑制剂(immune checkpoint inhibitors,ICIs)的肿瘤免疫治疗在近10年取得了重要进展,程序性死亡因子-1(PD-1)/程序性死亡因子配体-1(PD-L1)抗体治疗则成为肿瘤治疗领域最具潜力的新型疗法。中国肿瘤学者与发达国家学者基本同步开展的肿瘤免疫疗法的临床实践,进一步验证了肿瘤免疫治疗的效果。伴随临床应用数据的积累,ICIs抗肿瘤疗法逐渐暴露出很多不足,如总体治疗应答率偏低、获得性耐药机制复杂以及免疫相关不良反应(irAEs)多有发生等。这些问题都值得引起相关领域专家重视。本文总结了近年来国内外ICIs的临床实践成果,深入分析了当前ICIs疗法面临的挑战,探讨并提出了改善患者获益的策略。     

老年肿瘤免疫检查点抑制剂临床治疗进展

免疫检查点抑制剂(immune checkpoint inhibitors, ICIs)是当今肿瘤治疗领域的革命性突破, 改变了多种肿瘤治疗模式。老年人占肿瘤现患人数及死亡人数的绝大部分, 老年肿瘤患者存在免疫衰老、自身免疫性疾病及感染性疾病发生率高、肿瘤突变负荷与年轻患者存在差异等均可能影响ICIs疗效。在大部分ICIs临床试验中, 老年肿瘤患者在受试人群中未能占据应有比例, 亚组分析及荟萃分析结果提示年龄对疗效及免疫相关不良反应的发生影响较小。临床医生可参考相关试验数据, 在体能状态较好的老年肿瘤患者中使用ICIs, 以积累更多的真实世界数据。     

ECMO联合CRRT治疗爆发性心肌炎合并多脏器衰竭患者的一例护理体会*上海市东方医院(200123) 段婷婷 高彩萍 周如女

总结临床应用体外膜肺氧合（Extracorporeal membrane oxygenation,ECMO）联合肾脏替代治疗(Continuous renal replacement therapy,CRRT)治疗爆发性心肌炎合并多脏器衰竭患者的护理经验。方法：通过监测我科收治的一例爆发性心肌炎合并多脏器衰竭患者,在ECMO联合CRRT治疗期间观察患者生命体征的变化及康复情况,并做好相关护理记录,评估两者联合治疗此类病例的效果。 结果：结合多脏器功能支持治疗,患者在我科治疗46天后病情稳定,各脏器功能基本恢复正常,转普通病房后痊愈出院。结论：ECMO联合CRRT配合有效的护理是成功治愈爆发性心肌炎合并多脏器衰竭的重要保证。     

爆发性心肌炎伴心源性休克1例的急救护理

爆发性心肌炎是严重心肌损害性疾病,发病急骤,病情进展迅速,病程凶险,病死率高,临床表现有阿-斯综合征、心力衰竭、心源性休克、急性肾功能衰竭等[1]。2010年9月,本院ICU收治1例爆发性心肌炎伴全心衰竭、心源性休克、急性肾功能衰竭患者,经积极抢救,病情稳定后转普通病房继续治疗。现将急救护理报告如下。     

靶向联合免疫检查点抑制剂治疗对肝细胞癌患者心肌肌钙蛋白T的影响

目的 探讨肝细胞癌患者靶向联合免疫检查点抑制剂（immune checkpoint inhibitors, ICIs）治疗过程中出现心肌肌钙蛋白T(cTnT)升高的发生率及临床特征。方法 收集2017年1月至2021年12月复旦大学附属中山医院厦门医院肝肿瘤内科住院治疗的125例接受靶向联合ICIs治疗的肝细胞癌患者临床资料，根据治疗过程中cTnT水平变化分为c TnT正常组（cTnT<0.03 ng/mL,n=114）和cTnT升高组（cTnT≥0.03 ng/mL,n=11），分析2组患者的基线特征以及c TnT升高组患者cTnT升高前后的临床指标改变。结果 肝细胞癌患者靶向联合ICIs治疗过程中cTnT升高发生率为8.8%(11/125)，其中心肌炎的发生率为0.8%(1/125)。高龄、糖尿病史、心脏疾病史可能是cTnT升高的危险因素。11例患者c TnT升高后左心室射血分数显著下降（P=0.020），左心室舒张末期内径显著减小（P=0.013），白介素2受体水平显著增加（P=0.038）。结论 靶向联合ICIs治疗肝细胞癌可引起患者c TnT升高；监测c TnT变化有助...     

V-A ECMO联合CRRT治疗急性爆发性心肌炎合并多脏器功能衰竭患者的护理

急性爆发性心肌炎病情危重、进展迅速、病死率高,能在较短时间内出现心功能失代偿和循环呼吸衰竭,若不及时救治,患者可能在数小时至数天内死于心功能衰竭。体外膜肺氧合(ECMO)技术是一种持续体外生命体征治疗方法,应用体外设备替代或部分替代人的心、肺功能,支持生命以争取心、肺病变治愈及功能恢复的机会,可持续维持生命体征1周至半个月时间[1]。ECMO可应用于重症爆发性心肌炎引起的难治性心源性休克和致命性心律失常患者,我院于2019年9月应用股静脉、动脉插管建立体外膜肺氧合(V-A ECMO)联合肾脏替代疗法(CRRT)成功救治1例急性爆发性心肌炎合并多脏器功能衰竭患者,ECMO治疗易出现多种严重并发症,正确有效的护理措施可以延长ECMO使用时间,有效预防并发症的发生。现报告如下。     

体外膜肺氧合治疗暴发性心肌炎的报道一例

心肌炎中以感染性心肌炎最为常见,普通心肌炎通常没有明显的临床症状,但暴发性心肌炎会出现心衰等循环不稳危及生命安全的情况。本文对我科应用体外膜肺氧合成功救治1例暴发性心肌炎患者进行个案报道。     

1例免疫检查点抑制剂相关暴发性心肌炎患者的护理

心肌炎是免疫检查点抑制剂相关的高致死率免疫不良反应,其诊断、治疗及护理均较为复杂。该文总结1例低分化肺腺癌患者应用免疫检查点抑制剂并发暴发性心肌炎患者的护理,护理要点包括病情监测与预评估、体外膜肺氧合支持的护理、降低感染加重风险、并发症的预防与护理、康复指导和健康教育。经过25 d的积极治疗和精心护理,患者病情好转并顺利出院,电话随访6个月,状况良好。     

Disseminated coxsackievirus B fulminant myocarditis in an immunocompetent adult: A case report: Case of disseminated coxsackievirus myocarditis

Coxsackieviral myocarditis is associated with systemic involvement in neonates; however, fulminant coxsackieviral myocarditis is rare in adults, and its dissemination with fatal myocarditis involving kidneys, liver, and adrenal is further rarely reported. We report a case of fulminant myocarditis along with dissemination of coxsackievirus, which was clinically unrecognized.     

Immune checkpoint inhibitor–associated myocarditis: manifestations and mechanisms

Immune checkpoint inhibitors (ICIs) have transformed the treatment of various cancers, including malignancies once considered untreatable. These agents, however, are associated with inflammation and tissue damage in multiple organs. Myocarditis has emerged as a serious ICI-associated toxicity, because, while seemingly infrequent, it is often fulminant and lethal. The underlying basis of ICI-associated myocarditis is not completely understood. While the importance of T cells is clear, the inciting antigens, why they are recognized, and the mechanisms leading to cardiac cell injury remain poorly characterized. These issues underscore the need for basic and clinical studies to define pathogenesis, identify predictive biomarkers, improve diagnostic strategies, and develop effective treatments. An improved understanding of ICI-associated myocarditis will provide insights into the equilibrium between the immune and cardiovascular systems.     

Fulminant diabetes due to immune checkpoint inhibitors in the emergency department

Immune checkpoint inhibitors (ICIs) are of growing importance in new cancer therapies, exposing patients to various and potentially severe immune-related adverse events and placing emergency physicians on the front line when they occur. If endocrine toxicity is a well-known complication of ICIs, fulminant diabetes with diabetic ketoacidosis is exceptional. We present a case of fulminant diabetes after only two cycles of pembrolizumab in a 53-year-old man with a history of metastatic lung cancer who presented to our emergency department with coma and acidosis revealing diabetic ketoacidosis. The patient was rehydrated and treated with insulin and recovered quickly. Lung toxicity was also suspected on CT-scan findings. This rare and life-threatening complication that developed unusually early during the treatment course may be challenging in a cancer patient. Therefore, emergency physicians should investigate symptoms in patients treated with checkpoint inhibitors and consider toxicity when they present to the ED with complaints compatible with an immune-related adverse event.     

Co-infection with two Chlamydophila species in a case of fulminant myocarditis

OBJECTIVE: The aim of this study is to describe a case of fulminant myocarditis caused by co-infection with Chlamydophila pneumoniae and Chlamydophila psittaci in order to facilitate diagnosis and clinical management of patients suffering from this rare but life-threatening condition. DESIGN: Case report. SETTING: Intensive care unit of Innsbruck Medical University. PATIENT: A 24-yr-old patient admitted with septicemia and cardiac failure. INTERVENTIONS: Cardiopulmonary resuscitation, extracorporal membrane oxygenation, implantation of an extracorporal cardiac assist device, and antibiotic treatment with erythromycin. MEASUREMENTS AND MAIN RESULTS: Cp. pneumoniae and Cp. psittaci were identified by means of polymerase chain reaction and electron microscopy in the patient's myocytes. Successful weaning off the ventricular assist device was performed within 2 wks after commencement of antibiotic therapy. CONCLUSIONS: This case report demonstrates co-infection with Cp. pneumoniae and Cp. psittaci to be a hitherto unknown cause of fulminant myocarditis. There is a particular risk of misdiagnosis of viral myocarditis, which must be avoided. Patients should be transferred to a center where extracorporal membrane oxygenation therapy and molecular diagnosis of all members of the family Chlamydiaceae are available.     

Fulminant myocarditis presenting with wide complex tachycardia

Fulminant myocarditis is an uncommon diagnosis characterized by cardiac failure preceded by symptoms of a viral illness. Presentation can frequently mimic acute myocardial infarction. The electrocardiographic changes are frequently nonspecific, but include ST segment elevation and T wave changes, as well as conduction abnormalities. We report the case of a patient with fulminant myocarditis that presented with sinus rhythm, a conduction system abnormality, and severe ST segment elevation mimicking ventricular tachycardia. Myocarditis should be considered in young persons with unexplained heart failure and similar electrocardiographic abnormalities.     

Myocardite aiguë fulminante chez une femme enceinte traitée par assistance circulatoire

Fulminant myocarditis is a rare inflammatory affecting relatively young adult. We report a case of 29- year-old pregnant woman with an acute intraoperative onset of a severe heart failure. A rapid and accurate diagnostic approach suggested an acute fulminant myocarditis. Initial hemodynamic support without immunosuppressive and viral therapy resulted in a partial recovery within a two week. Patients presenting with acute fulminant myocarditis with unknown etiology can have a complete recovery with an appropriate and rapid timing of an aggressive hemodynamic support including levosimendan and extracorporeal membrane oxygenation.