{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T01:35:01Z","timestamp":1787016901952,"version":"build-2736575974"},"reference-count":15,"publisher":"BMJ","issue":"1","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2024,12,29]]},"published-print":{"date-parts":[[2025,1]]},"abstract":"<jats:p>The increasing use of immune checkpoint inhibitors in clinical practice is associated with a broad spectrum of immune-related adverse events, such as cardiac, rheumatological and neurological toxicities. Myocarditis is a life-threatening complication, and the concurrent development of myocarditis, myositis and\/or myasthenia leads to difficulties in diagnosis, management and treatment. We describe a case presenting with this triple M overlap syndrome following pembrolizumab treatment.<\/jats:p>\n                  <jats:p>A man in his 80s with a background of chronic ischaemic heart disease, receiving pembrolizumab as first-line treatment for microsatellite instability locally advanced gastric cancer, presented after the second dose of treatment with muscle weakness, binocular diplopia and left ptosis. Elevated transaminases, creatine kinase and high-sensitivity troponin-T levels were revealed. ECG monitoring showed the development of an atrioventricular block, needing a temporary pacemaker. Immune-related myocarditis, myasthenia and myositis were suspected. High-dose corticosteroids were administered without clinical benefit, so an escalation of immunosuppression was needed, using infliximab and immunoglobulins.<\/jats:p>","DOI":"10.1136\/bcr-2024-260349","type":"journal-article","created":{"date-parts":[[2025,1,21]],"date-time":"2025-01-21T02:20:17Z","timestamp":1737426017000},"page":"e260349","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":6,"title":["Triple M overlap syndrome following pembrolizumab treatment: importance of multidisciplinary approach"],"prefix":"10.1136","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1017-4568","authenticated-orcid":false,"given":"Luc\u00eda","family":"G\u00f3mez","sequence":"first","affiliation":[{"name":"Medical Oncology, Alicante Institute for Health and Biomedical Research, Alicante, Comunidad Valenciana, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Teresa","family":"Lozano","sequence":"additional","affiliation":[{"name":"Cardiology, Alicante Institute for Health and Biomedical Research, Alicante, Comunidad Valenciana, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vega","family":"Jovani","sequence":"additional","affiliation":[{"name":"Rheumatology, Alicante Institute for Health and Biomedical Research, Alicante, Comunidad Valenciana, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Natividad","family":"Mart\u00ednez-Banaclocha","sequence":"additional","affiliation":[{"name":"Medical Oncology, Alicante Institute for Health and Biomedical Research, Alicante, Comunidad Valenciana, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,1,20]]},"reference":[{"key":"2025082707091366000_18.1.e260349.1","doi-asserted-by":"publisher","DOI":"10.1016\/j.annonc.2022.07.004"},{"key":"2025082707091366000_18.1.e260349.2","doi-asserted-by":"crossref","first-page":"895","DOI":"10.1001\/jamaoncol.2021.0275","article-title":"Assessment of Pembrolizumab Therapy for the Treatment of Microsatellite Instability-High Gastric or Gastroesophageal Junction Cancer Among Patients in the KEYNOTE-059, KEYNOTE-061, and KEYNOTE-062 Clinical Trials","volume":"7","author":"Chao","year":"2021","journal-title":"JAMA Oncol"},{"key":"2025082707091366000_18.1.e260349.3","doi-asserted-by":"crossref","DOI":"10.1016\/j.esmoop.2020.100036","article-title":"Predictive role of microsatellite instability for PD-1 blockade in patients with advanced gastric cancer: a meta-analysis of randomized clinical trials","volume":"6","author":"Pietrantonio","year":"2021","journal-title":"ESMO Open"},{"key":"2025082707091366000_18.1.e260349.4","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMra1703481"},{"key":"2025082707091366000_18.1.e260349.5","doi-asserted-by":"publisher","DOI":"10.1002\/onco.13931"},{"key":"2025082707091366000_18.1.e260349.6","doi-asserted-by":"crossref","DOI":"10.1016\/j.esmoop.2021.100317","article-title":"How we identify and treat neuromuscular toxicity induced by immune checkpoint inhibitors","volume":"6","author":"Jordan","year":"2021","journal-title":"ESMO Open"},{"key":"2025082707091366000_18.1.e260349.7","first-page":"511","article-title":"Immune checkpoint inhibitor-induced myocarditis, myositis, myasthenia gravis and transaminitis: a case series and review","volume":"14","author":"Wai Siu","year":"2022","journal-title":"Immunotherapy (Los Angel)"},{"key":"2025082707091366000_18.1.e260349.8","doi-asserted-by":"publisher","DOI":"10.1016\/j.annonc.2022.10.001"},{"key":"2025082707091366000_18.1.e260349.9","doi-asserted-by":"crossref","first-page":"1721","DOI":"10.1001\/jamaoncol.2018.3923","article-title":"Fatal Toxic Effects Associated With Immune Checkpoint Inhibitors: A Systematic Review and Meta-analysis","volume":"4","author":"Wang","year":"2018","journal-title":"JAMA Oncol"},{"key":"2025082707091366000_18.1.e260349.10","doi-asserted-by":"crossref","first-page":"1150","DOI":"10.1016\/S1474-4422(23)00335-6","article-title":"Neurological adverse events related to immune-checkpoint inhibitors in Spain: a retrospective cohort study","volume":"22","author":"Fonseca","year":"2023","journal-title":"Lancet Neurol"},{"key":"2025082707091366000_18.1.e260349.11","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1016\/j.ajem.2021.03.005","article-title":"Immune checkpoint inhibitor-associated myasthenia gravis, myositis, and myocarditis overlap syndrome","volume":"46","author":"Lipe","year":"2021","journal-title":"Am J Emerg Med"},{"key":"2025082707091366000_18.1.e260349.12","doi-asserted-by":"crossref","first-page":"1527","DOI":"10.1007\/s00432-019-02927-x","article-title":"Immune checkpoint inhibitor therapy and myocarditis: a systematic review of reported cases","volume":"145","author":"Atallah-Yunes","year":"2019","journal-title":"J Cancer Res Clin Oncol"},{"key":"2025082707091366000_18.1.e260349.13","doi-asserted-by":"crossref","first-page":"1733","DOI":"10.1093\/eurheartj\/ehaa051","article-title":"Cardiovascular magnetic resonance in immune checkpoint inhibitor-associated myocarditis","volume":"41","author":"Zhang","year":"2020","journal-title":"Eur Heart J"},{"key":"2025082707091366000_18.1.e260349.14","doi-asserted-by":"crossref","first-page":"1421","DOI":"10.1002\/acn3.654","article-title":"Immune checkpoint inhibitors in the onset of myasthenia gravis with hyperCKemia","volume":"5","author":"Takamatsu","year":"2018","journal-title":"Ann Clin Transl Neurol"},{"key":"2025082707091366000_18.1.e260349.15","doi-asserted-by":"crossref","first-page":"218","DOI":"10.1111\/cen3.12611","article-title":"Anti\u2010striational antibodies: Expanding their clinical significance","volume":"11","author":"Suzuki","year":"2020","journal-title":"Clinical & Exp Neuroim"}],"container-title":["BMJ Case Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bcr-2024-260349","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,27]],"date-time":"2025-08-27T14:09:22Z","timestamp":1756303762000},"score":1,"resource":{"primary":{"URL":"https:\/\/casereports.bmj.com\/lookup\/doi\/10.1136\/bcr-2024-260349"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,1]]},"references-count":15,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025,1,20]]},"published-print":{"date-parts":[[2025,1]]}},"alternative-id":["10.1136\/bcr-2024-260349"],"URL":"https:\/\/doi.org\/10.1136\/bcr-2024-260349","relation":{},"ISSN":["1757-790X"],"issn-type":[{"value":"1757-790X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,1]]}}}