PDF(Pubmed)
Abstract：
An 85-year-old man was diagnosed with hepatocellular carcinoma (HCC) and was initially treated with transarterial chemoembolization (TACE) and sorafenib. He was then switched to nivolumab and ipilimumab in view of sorafenib intolerance and disease progression. Subsequently, he developed dysphagia and generalized dyspnea culminating in hypercapnic respiratory failure requiring intubation. After an extensive workup, the etiology of his fluctuating respiratory issues was narrowed down to a likely neuromuscular process. Although antibodies to acetylcholine receptors (anti-AChR Ab) were negative, he was treated with high-dose steroids due to clinical concern for Immune Checkpoint Inhibitor (ICI) neurotoxicity. His recovery post immune suppression and absence of recurrence after ICI cessation suggested the possibility of this being an ICI neurotoxicity manifesting with myasthenic symptoms. Incidentally, he also had evidence of aseptic meningitis on cerebrospinal fluid analysis further strengthening this diagnosis. This case illustrates the importance of early recognition of ICI toxicity which will in turn lead to initiating treatments sooner and also decreasing the length of illness.
摘要：
一名85岁的男性被诊断出患有肝细胞癌（HCC），最初接受了经动脉化疗栓塞（TACE）和索拉非尼治疗。鉴于索拉非尼不耐受和疾病进展，他随后改用nivolumab和ipilimumab。随后，他出现吞咽困难和广泛性呼吸困难，最终导致需要插管的高碳酸血症性呼吸衰竭。经过广泛的检查，他的波动呼吸问题的病因被缩小到可能的神经肌肉过程。尽管乙酰胆碱受体抗体（抗AChRAb）呈阴性，由于临床关注免疫检查点抑制剂(ICI)神经毒性,患者接受大剂量类固醇治疗.他在免疫抑制后恢复，ICI停止后没有复发，这表明这可能是ICI神经毒性，表现为肌无力症状。顺便说一句,他还对脑脊液分析有无菌性脑膜炎的证据进一步加强了这一诊断。这种情况说明了早期识别ICI毒性的重要性，这反过来会导致更快地开始治疗，并减少疾病的持续时间。
