Dual immune checkpoint inhibitor cardonilumab induces immune myocarditis in a patient with cancer‑related myocardial metastasis: A case report

Cadonilimab is a bispecific immune checkpoint inhibitor (ICI) targeting both programmed death 1 and cytotoxic T-lymphocyte activator 4, thus blocking both immune checkpoint pathways. Cadonilimab exerts several antitumor effects and is used to treat various types of cancer, including gastric, liver, lung, cervical and pancreatic cancer, and esophageal squamous cell carcinoma. However, ICIs are also associated with the onset of several immune-related adverse events (irAEs), including immune-mediated pneumonia, immune-mediated colitis and myocarditis. Among them, myocarditis is a rare but potentially life-threatening side effect. The current study describes the case of a 49-year-old patient with lung cancer and myocardial metastasis, who developed myocarditis and heart failure following therapy with cadonilimab. After three cycles of cadonilimab treatment for 2 months, the patient experienced persistent wheezing and a paroxysmal cough, prompting hospitalization. Multidisciplinary assessment and laboratory findings supported a diagnosis of immune-related myocarditis. Following treatment with low-dose diuretics and intravenous methylprednisolone (adjusted dose), and management of anemia, the patient recovered well and was discharged on hospital day 21. This case study highlights the importance of vigilance for severe cardiovascular complications associated with dual ICI cadonilimab immunotherapy. Therefore, close outpatient monitoring is critical during treatment with cadonilimab, with particular attention awarded to the overall condition of the patients. Special consideration should be given to risk factors, such as cardiac metastasis and impaired lung function, which could predispose patients to irAEs associated with immunotherapy, and more particularly with myocarditis. Based on the current experience, the present study offers practical recommendations for the prevention of cadonilimab-induced myocarditis to improve patient outcomes.