Case report of fatal myocarditis with toripalimab and axitinib combination therapy

We report a 65-year-old male with advanced renal cell carcinoma who developed ICI-associated myocarditis following 4 cycles of combination immunotherapy. The patient presented with progressive dyspnea and fatigue, necessitating hospitalization. Comprehensive diagnostic evaluation confirmed grade 4 myocarditis based on clinical features, elevated cardiac biomarkers, echocardiographic abnormalities, and exclusion of infectious causes. Treatment consisted of multimodal immunosuppressive and life-support therapies, including high-dose methylprednisolone, intravenous IVIG, therapeutic plasma exchange, VA-ECMO, and empiric broad-spectrum antibiotics guided by microbial surveillance. Despite transient hemodynamic stabilization, the patient ultimately progressed to multiorgan failure and died on day 24 of hospitalization. This case underscores the life-threatening nature of ICI-associated myocarditis and highlights the critical need for early recognition, aggressive supportive management, and proactive anti-infective prophylaxis in patients receiving combination immunotherapy.