Polymyalgia rheumatica as a complication of immune checkpoint inhibitors treatment due to malignant melanoma

Authors: R. Roman 1;  Z. Řehák 2;  A. Poprach 3;  P. Němec 1
Authors‘ workplace: Fakultní nemocnice u sv. Anny v Brně, II. interní klinika, Oddělení revmatologie, Brno 1;  Masarykův onkologický ústav, Oddělení nukleární medicíny, Regionální centrum aplikované molekulární onkologie (RECAMO), Brno 2;  Masarykův onkologický ústav, Klinika komplexní onkologické péče, Brno 3
Published in: Čes. Revmatol., 26, 2018, No. 2, p. 80-86.
Category: Case Report


In recent years immune checkpoint inhibitors (ICI) have been used to treat malignant melanoma (MM). Their use is often accompanied with various grades of immune related adverse events (irAEs). Polymyalgia rheumatica (PMR) is of rare irAEs. PMR is an autoinflammatory condition characterized by stiffness around the shoulders and hip girdle. Guidelines for irAEs treatment have not yet been established. Recent reports have been based on clinical experience only. Most irAEs are responsive to glucocorticoids and therefore could be effectively treated by temporary immunosuppression. Also useful in less severe cases is delaying of ICI administration or symptomatic treatment. In more severe cases it is possible to treat by intravenous (i.v.) administration of glucocorticoids or by adding other immunosuppressants. Malignant melanomas are characterized by high accumulation of fludeoxyglucose (18F) (FDG). Therefore PET/CT imaging using FDG is ideal for diagnostics and monitoring of treatment response due to its high accumulation in malignant melanoma tissue. High accumulation of FDG is also detected in areas characteristic for PMR. Casuistics of sucessful treatment of a seventy-six-year-old patient in whom polymyalgia rheumatica developed as a result of MM treatment using ICI nivolumab is being presented.

Key words:

Polymyalgia rheumatica, malignant melanoma, immune checkpoint inhibitors, FDG PET/CT


1.  Dejaco C, Brouwer E, Mason JC, Buttgereit F, Matteson EL, Dasgupta B. Giant cell arteritis and polymyalgia rheumatica: Current challenges and opportunities. Nat Rev Rheumatol 2017; 13 (10): 1–15.

2.  Calabrese C, Kirchner E, Kontzias K, Velcheti V, Calabrese LH. Rheumatic immune-related adverse events of checkpoint therapy for cancer: Case series of a new nosological entity. RMD Open 2017; 3 (2): e000412corr1.

3.  Němec P, et al. Revmatologie pro praxi. Praha, Mladá fronta, 2016.

4.  Docken W. Clinical manifestations and diagnosis of polymyalgia rheumatica. UpToDate 2018. Online. Dostupné na:  http://www.uptodate.com.proxycu.wrlc.org/contents/clinical-manifestations-and-diagnosis-of-polymyalgia-rheumatica?source=search_result&search=polymyalgia+ rheumatica&selectedTitle=1~76#H4

5.  Docken W. Clinical manifestations of giant cell (temporal) arteritis. UpToDate 2018. Online. Dostupné na:  https://www.uptodate.com/contents/clinical-manifestations-of-giant-cell-temporal-arteritis?search=giant cell arteritis&source=search_result&selectedTitle=2~ 125&usage_type=default&display_rank=2

6.  Kodet O, Krajsová I. Maligní melanom, incidence, rizikové faktory a jeho časná diagnostika. Onkologie 2017; 11 (3): 138–43.

7.  Karlsson AK, Saleh SN. Checkpoint inhibitors for malignant melanoma: A systematic review and meta-analysis. Clin Cosmet Investig Dermatol 2017; 10: 325–339.

8.  Schadendorf D, Fisher DE, Garbe C, Gershenwald JE, Grob JJ, Halpern A, et al. Melanoma. Nat Rev Dis Primers 2015; 1: 15003.

9.  Suarez-Almazor ME, Kim ST, Abdel-Wahab N, Diab A. Immune-related adverse events with use of checkpoint inhibitors for immunotherapy of cancer. Arthritis Rheumatol 2017; 69 (4): 687–699.

10. Scott JL. Nivolumab: A review in advanced melanoma. Drugs 2015; 75 (12): 1413–1424.

11. Postow MA, Sidlow R, Hellmann MD. Immune-related adverse events associated with immune checkpoint blockade. N Engl J Med 2018; 378 (2): 158–68.

12. Larkin L, Chiarion-Sileni V, Gonzalez R, Grob JJ, Cowey CL, Lao CD, Schadendorf D. Combined nivolumab and ipilimumab or monotherapy in untreated melanoma. N Engl J Med 2015; 373 (1): 23–34.

13. Robert C, Long GV, Brady B, Dutriaux C, Maio M, Mortier L et al. Nivolumab in previously untreated melanoma without BRAF mutation. N Engl J Med 2015; 372 (4): 320–330.

14. Wolchok JD, Chiarion-Sileni V, Gonzalez R, Rutkowski P, Grob JJ, Cowey CL, et al. Overall survival with combined nivolumab and ipilimumab in advanced melanoma. N Engl J Med 2017; 377(4): 1345–56.

15. Haanen J, Carbonnel F, Robert C, Kerr KM, Peters S, Larkin J, et al. Management of toxicities from immunotherapy: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 2017; 28 (Suppl. 4): iv119–iv142.

16. Bernier M, Guillaume C, Leon N, Alexandre J, Hamel-Senecal L, Chretien B, et al. Nivolumab causing a polymyalgia rheumatica in a patient with a squamous non-small cell lung cancer, J Immunother 2017; 40 (4): 129–131.

17. Belkhir R, Burel SL, Dunogeant L, Marabelle A, Hollebecque A,Besse B, et al. Rheumatoid arthritis and polymyalgia rheumatica occurring after immune checkpoint inhibitor treatment. Ann Rheum Dis 2017; 76 (10): 1747–1750.

18. Nakamagoe K, Moriyama T, Maruyama H, Yokosawa M, Hara T, Tanaka S, et al. Polymyalgia rheumatica in a melanoma patient due to nivolumab treatment. J Cancer Res Clin Oncol 2017; 143 (7): 1357–1358.

19. Zimmer L, Goldinger SM, Hofmann L, Loquai C, Ugurel S, Thomas I et al. Neurological, respiratory, musculoskeletal, cardiac and ocular side-effects of anti-PD-1 therapy. Eur J Cancer 2016; 60: 210–225.

20. Goldstein BL, Gedmintas L, Todd DJ. Drug – associated polymyalgia rheumatica/ giant cell arteritis occurring in two patients after treatment with ipilimumab, an antagonist of CTLA-4. Arthritis Rheumatol 2014; 66 (3): 768–769.

21. ACTEMRA (tocilizumab) injection 2017. (Online). Available: https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/125276s114lbl.pdf.

22. Kim ST, et al. Successful treatment of arthritis induced by checkpoint inhibitors with tocilizumab: a case series. Ann Rheum Dis 2017; 76 (12): 2061–2064.

23. Řehák Z, Lakomý R, Fait V. Onkologie v obrazech. Klin Onkol 2015; 28 (2): 143–4.

24. Řehák Z, Sprlakova-Pukova A, Kazda T, Fojtik Z, Vargova L, Němec P. 18F-FDG PET/CT in polymyalgia rheumatica – a pictorial review. Br J Radiol 2017; 90 (1076): 20170198. 25.     Randazzo CT, Bernard AW, Rund DA. Metastatic prostate cancer mimicking polymyalgia rheumatica. Case Rep Emerg Med 2011; 2011: 695320.

26. Azar L, Khasnis A. Paraneoplastic rheumatologic syndromes. Curr Opin Rheumatol 2013; 25 (1): 44–49.

27. Coelho S, Magalhaes H, Correia J. Polymyalgia rheumatica and pulmonary adenocarcinoma: A case report and literature review. Porto Biomed J 2017; 2 (3): 93–95.

28. Ji J, Liu X, Sundquist K, Sundquist J, Hemminki K. Cancer risk in patients hospitalized with polymyalgia rheumatica and giant cell arteritis: A follow-up study in Sweden. Rheumatology 2010; 49 (6): 1158–1163.

29. Muller S, Hider SL, Belcher L, Helliwell T, Mallen CD. Is cancer associated with polymyalgia rheumatica? A cohort study in the General Practice Research Database. Ann Rheum Dis 2014; 73 (10): 1769–1773.

30. Pfeifer EC, Crowson CS. Polymyalgia rheumatica and its association with cancer.  Rheumatol Curr Res 2015; Suppl 6 pii: 003.

31. Manzo C, Natale M. Polymyalgia rheumatica and cancer risk: The importance of the diagnostic set. Open Access Rheumatol Res Rev 2016; 8: 93–95.

Dermatology & STDs Paediatric rheumatology Rheumatology
Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.


Don‘t have an account?  Create new account