Teaching NeuroImage: Immune Checkpoint Inhibitor-Related Fasciitis and Myositis With Perifascicular Atrophy

A 58-year-old man with melanoma treated with ipilimumab/nivolumab presented with pain, limited joint mobility, and proximal weakness without oculobulbar weakness, dyspnea, or rash. EMG demonstrated positive sharp waves, fibrillations, and myopathic units. Extremity MRI showed diffuse fascial and mild muscle enhancement consistent with fasciitis/mild myositis (Figure). Creatinine kinase was normal. PET-CT demonstrated diffusely fluorodeoxyglucose-avid lymph nodes and muscles; lymph node biopsy revealed granulomatous inflammation suggesting immune checkpoint inhibitor-related inflammatory reaction. Biceps biopsy demonstrated perifascicular atrophy (PA) and fascial/perimysial perivascular inflammation (Figure).

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