Myocardial immune vulnerability unmasked after treatment with immune checkpoint inhibitors: a case report

Eduardo Zatarain-Nicolás; Laura Yousif; Francisco Diaz-Crespo; Enrique Ortega-Sollero; José Ángel Arranz; Javier Bermejo; Pilar Martín; Wouter C. Meijers

doi:10.1093/ehjcr/ytag579

Myocardial immune vulnerability unmasked after treatment with immune checkpoint inhibitors: a case report

Eduardo Zatarain-Nicolás^*
, Laura Yousif
, Francisco Diaz-Crespo
, Enrique Ortega-Sollero
, José Ángel Arranz
, Javier Bermejo
, Pilar Martín
, Wouter C. Meijers

^*Corresponding author for this work

Cardiology

Hospital General Universitario Gregorio Marañon
Centro de Investigación Biomédica en Red (CIBER)
Centro Nacional de Investigaciones Cardiovasculares
Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBER-CV)
Instituto Carlos III
Centro Nacional de Investigaciones Cardiovasculares (CNIC)

Research output: Contribution to journal › Article › Academic › peer-review

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Abstract

Background:

Although uncommon (incidence <1%), cardiac immune-related adverse events (irAEs) associated with immune checkpoint inhibitor (ICI) therapy can be fatal. Their underlying mechanisms remain incompletely understood, although autoimmune predisposition and cross-antigen responses have been implicated.

Case summary:

We report the case of a young, immunologically predisposed patient with renal cell carcinoma who developed recurrent episodes of myocardial injury following an initial mild ICI-related myocarditis. Subsequent viral infections acted as triggers for repeated myocardial damage despite discontinuation of ICI therapy.

Discussion:

Novel immune biomarkers were identified, and distinctive findings on endomyocardial biopsy, together with tumour protein expression patterns, provided insight into the patient’s heightened myocardial immune vulnerability to viral infections. This case highlights the complex interplay between ICI therapy, host immune predisposition, and viral triggers in the pathogenesis of cardiac irAEs.

Original language	English
Article number	ytag579
Journal	European Heart Journal - Case Reports
Volume	10
Issue number	8
DOIs	https://doi.org/10.1093/ehjcr/ytag579
Publication status	Published - Aug 2026

Bibliographical note

Publisher Copyright:
© The Author(s) 2026. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

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Myocardial immune vulnerability unmasked after treatment with immune checkpoint inhibitorsFinal published version, 1.09 MBLicence: CC BY

Cite this

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title = "Myocardial immune vulnerability unmasked after treatment with immune checkpoint inhibitors: a case report",

abstract = "Background: Although uncommon (incidence <1\%), cardiac immune-related adverse events (irAEs) associated with immune checkpoint inhibitor (ICI) therapy can be fatal. Their underlying mechanisms remain incompletely understood, although autoimmune predisposition and cross-antigen responses have been implicated. Case summary: We report the case of a young, immunologically predisposed patient with renal cell carcinoma who developed recurrent episodes of myocardial injury following an initial mild ICI-related myocarditis. Subsequent viral infections acted as triggers for repeated myocardial damage despite discontinuation of ICI therapy. Discussion: Novel immune biomarkers were identified, and distinctive findings on endomyocardial biopsy, together with tumour protein expression patterns, provided insight into the patient{\textquoteright}s heightened myocardial immune vulnerability to viral infections. This case highlights the complex interplay between ICI therapy, host immune predisposition, and viral triggers in the pathogenesis of cardiac irAEs.",

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AU - Zatarain-Nicolás, Eduardo

AU - Yousif, Laura

AU - Diaz-Crespo, Francisco

AU - Ortega-Sollero, Enrique

AU - Arranz, José Ángel

AU - Bermejo, Javier

AU - Martín, Pilar

AU - Meijers, Wouter C.

N1 - Publisher Copyright: © The Author(s) 2026. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

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N2 - Background: Although uncommon (incidence <1%), cardiac immune-related adverse events (irAEs) associated with immune checkpoint inhibitor (ICI) therapy can be fatal. Their underlying mechanisms remain incompletely understood, although autoimmune predisposition and cross-antigen responses have been implicated. Case summary: We report the case of a young, immunologically predisposed patient with renal cell carcinoma who developed recurrent episodes of myocardial injury following an initial mild ICI-related myocarditis. Subsequent viral infections acted as triggers for repeated myocardial damage despite discontinuation of ICI therapy. Discussion: Novel immune biomarkers were identified, and distinctive findings on endomyocardial biopsy, together with tumour protein expression patterns, provided insight into the patient’s heightened myocardial immune vulnerability to viral infections. This case highlights the complex interplay between ICI therapy, host immune predisposition, and viral triggers in the pathogenesis of cardiac irAEs.

AB - Background: Although uncommon (incidence <1%), cardiac immune-related adverse events (irAEs) associated with immune checkpoint inhibitor (ICI) therapy can be fatal. Their underlying mechanisms remain incompletely understood, although autoimmune predisposition and cross-antigen responses have been implicated. Case summary: We report the case of a young, immunologically predisposed patient with renal cell carcinoma who developed recurrent episodes of myocardial injury following an initial mild ICI-related myocarditis. Subsequent viral infections acted as triggers for repeated myocardial damage despite discontinuation of ICI therapy. Discussion: Novel immune biomarkers were identified, and distinctive findings on endomyocardial biopsy, together with tumour protein expression patterns, provided insight into the patient’s heightened myocardial immune vulnerability to viral infections. This case highlights the complex interplay between ICI therapy, host immune predisposition, and viral triggers in the pathogenesis of cardiac irAEs.

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Myocardial immune vulnerability unmasked after treatment with immune checkpoint inhibitors: a case report

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