28 year old woman diagnosed with chronic phase CML in June, 2017. WBC 65. Started on hydroxyurea and developed chest pain which continued when she was started on imatinib at 400mg od. Concurrently diagnosed with chronic hepatitis B and started on tenofovir. Chest pain persists and got worse transiently when imatinib started. Became somewhat cytopenic and imatinib reduced to 300mg od. Blood counts now normal. Has had full cardiac work up with stress test, Holter and echo with nothing positive. CT scan chest and pulmonary embolus work up all negative. Referred to me.
Nothing to find on exam including any chest wall tenderness.
I have suggested an autoimmune/inflammatory work up, but if this is negative, I have no thoughts about etiology. No interaction between imatinib and tenofovir described on searching.
Has anyone seen symptoms like this before? Managed how? Do we subscribe it all to anxiety?
Appreciate any comments or suggestions.

Hi Jeff, I have never seen this sort of reaction to a TKI. One thought would be coronary artery spasm which has been reported with imatinib and other TKIs. Localised myalgia or bone pain is probably more likely. Did anyone do an ECG during the pain? I would probably restart imatinib at 100 mg/day and build up very cautiously over the first few weeks.

I will also be very interested to see whether any other clinicians have had any similar experiences.

spasm was ruled out and she had a full work up including angiography

Hi Jeff. I never saw something like this. I think that chest pain has nothing to do with imatinib as it started already when she was assuming hydroxyurea. It is also hard to believe that it has something to do with CML as she has apparently a low risk disease responding to imatinib therapy. After your very complete check-up in all possible direction I think that I would really ascribe this pain to anxiety or to something from the psycho-social point of view. Do we have any idea on the cause of her hepatitis B infection?

ORIGINAL CASE:
28 year old woman diagnosed with chronic phase CML in June, 2017. WBC 65. Started on hydroxyurea and developed chest pain which continued when she was started on imatinib at 400mg od. Concurrently diagnosed with chronic hepatitis B and started on tenofovir. Chest pain persists and got worse transiently when imatinib started. Became somewhat cytopenic and imatinib reduced to 300mg od. Blood counts now normal. Has had full cardiac work up with stress test, Holter and echo with nothing positive. CT scan chest and pulmonary embolus work up all negative. Referred to me.
Nothing to find on exam including any chest wall tenderness.
I have suggested an autoimmune/inflammatory work up, but if this is negative, I have no thoughts about etiology. No interaction between imatinib and tenofovir described on searching.
Has anyone seen symptoms like this before? Managed how? Do we subscribe it all to anxiety?
Appreciate any comments or suggestions.