A patient in their early 70s with a history of lung cancer was admitted to the oncology department for routine assessment and next cycle of anticancer therapy. Previously, the patient had undergone a left upper lobectomy followed by 19 doses of pembrolizumab for lung cancer; the 20th dose was to be administered during this visit. The patient had a medical history of well-controlled diabetes and immune-related hypothyroidism associated with pembrolizumab use, and no other comorbidities or noteworthy family medical history. On admission, the patient denied any symptoms and had normal vital signs. However, the initial electrocardiogram (ECG) findings showed alarming features that alerted the physicians who ordered additional investigations (Figure, A). The patient’s troponin I level was 0.063 ng/mL (reference, <0.034 ng/mL; for µg/L, multiply by 1); brain-type natriuretic peptide level was 197 pg/mL (reference, <125 pg/mL; for ng/L, multiply by 1); and serum calcium level was 8.72 mg/dL (reference range, 8.5-10.5 mg/dL; for mmol/L, multiply by 0.25). Ten minutes after the initial ECG was performed, the patient complained of sudden-onset squeezing precordial chest pain with back pain and nausea.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Xuhong Geng, MD, Department of Function, Fourth Hospital of Hebei Medical University, No. 12, Jiankang Rd, Shijiazhuang 050011, China (firstname.lastname@example.org).
Published Online: May 8, 2023. doi:10.1001/jamainternmed.2023.0346
Conflict of Interest Disclosures: None reported.
Additional Information: Drs Zhang and Cheng are co−first authors and contributed equally to this work. The authors thank Prof Tong Liu (Second Hospital of Tianjin Medical University) and Prof Gary Tse (Kent and Medway Medical School) for their helpful comments.
Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:
It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.
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