# Case of Immune Checkpoint Inhibitor Induced Myasthenia Gravis

## TL;DR

An 85-year-old man with liver cancer developed myasthenia gravis-like symptoms after treatment with immune checkpoint inhibitors, highlighting the need for early recognition of such side effects.

## Contribution

This case report highlights ICI-induced myasthenia gravis as a rare but important neurotoxicity to recognize in cancer treatment.

## Key findings

- The patient developed myasthenic symptoms and respiratory failure after ICI treatment.
- Immune suppression led to recovery, supporting the ICI toxicity diagnosis.
- Aseptic meningitis in cerebrospinal fluid analysis further supported the diagnosis.

## 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.