Overlapping Syndrome of Myocarditis, Myositis, Transaminitis, and Myasthenia Gravis in a Patient with Hepatocellular Carcinoma after Treatment with Immune Checkpoint Inhibitors: A Case Report and Literature Review.

Introduction: Immune checkpoint inhibitors (ICIs) are widely used to treat various cancers but can induce immune-related adverse events (irAEs) in patients. Herein, we report the case of a 68-year-old patient with hepatocellular carcinoma who developed an overlapping syndrome of irAEs after receiving ICIs.

Case presentation: The patient received transcatheter arterial chemoembolization for hepatocellular carcinoma, followed by immunotherapy of 200 mg of camrelizumab every 3 weeks and 12 mg of lenvatinib mesylate daily. After receiving the second dose of camrelizumab treatment, the patient developed gradually worsening left eyelid ptosis and general weakness. One week later, the patient developed bilateral eyelid ptosis and suffocated while drinking water. Unfortunately, the patient was eventually diagnosed as ICI-related myocarditis, myositis, transaminitis, and myasthenia gravis based on a series of physical examinations. Subsequently, the patient was actively provided life support and symptomatic treatment. His symptoms greatly improved after treatment with methylprednisolone sodium succinate 40 mg once daily intravenously for 7 days, with gradually decreasing doses.

Conclusions: IrAEs are common after ICI treatment. After ICI treatment initiation, close monitoring, early detection, and treatment of irAEs is required to improve clinical outcomes.