Background

Over the past decade, a number of Disease Modifying Therapies (DMTs) for Multiple Sclerosis (MS) have been made available to help slow the progression of MS. The efficacy of these therapies depends on the extent of lymphocyte suppression, offering favorable outcomes in disease suppression, but present safety concerns that should be balanced. Alemtuzumab has been FDA approved for aggressive forms of Relapsing Remitting MS (RRMS) since 2014. It acts on the CD52 antigen present on B and T cells, thereby achieving lymphopenia. while it is highly efficacious, it has several warnings of autoimmunity, infusion reactions, strokes, and malignancies.

Objectives

The purpose of this abstract is to highlight a novel case study of possible alemtuzumab induced myocarditis. A quick literature review did not yield any findings of prior reports.

Methods

We present a 27 year old woman with a 10-year history of MS who had previously been treated with interferon, dimethyl fumarate, and fingolimod – all switched for either disease activity or intolerance. Alemtuzumab was initiated following these DMT failures.

Alemtuzumab was administered in January 2020 with pre-medications as per the package insert. On day 2 of her infusion, she developed asymptomatic bradycardia. Upon arrival on day 3, she reported intermittent epigastric pain overnight. Facial flushing was noted by the nurse and the infusion was held. In addition, she was having palpitations with fluctuations in heart rate. The RN hooked her up to EKG, which was significant for multiple PVCs, ST abnormalities and a right bundle branch block. At this point she was quickly transferred to the Emergency Department.

While in the ED, she quickly developed dyspnea and a productive cough. Due to desaturation, tachycardia and hypotension, she was admitted to the Intensive Care Unit for cardiogenic shock. Repeat chest Xray showed bilateral pulmonary edema. Troponins were uptrending and echocardiogram showed an ejection fraction of 10%. The diagnosis of acute drug induced myocarditis was made.

Results

The patient was treated with bipap and diuretics, after which heart rate and saturation progressively improved. Initial Cardiac MRI revealed an EF of 42%. Diffuse "mild" Late Gadolinium Enhancement, more consistent with inflammation and edema than myocardial fibrosis (scar).She was discharged home with a lifevest and on Digoxin, Toprol XL, Aldactone, and Losartan.

At four month follow up, repeat cardiac MRI showed improved EF to 54% with resolution of myocardial edema.

Conclusions

To our knowledge this is the first report of alemtuzumab induced myocarditis and while an isolated event, prescribers should be aware of this potential adverse effect.