A Case of Liver Cancer with Overlapping Myasthenia Gravis, Myocarditis, Seronegative Autoimmune Autonomic Ganglionopathy, and Myositis Symptoms Induced by Atezolizumab: A Case Report

Ryoko Shibuya; Kousuke Baba; Risako Furuta; Hiroki Maesaka; Hiroaki Hirosawa; Tadashi Bando; Akira Oshima; Hiroshi Onoda; Takamasa Nukui; Nobuhiro Dougu; Shuji Joho; Yuji Nakatsuji

doi:10.2169/internalmedicine.1801-23

Ryoko Shibuya, Kousuke Baba, Risako Furuta, Hiroki Maesaka, Hiroaki Hirosawa, Tadashi Bando, Akira Oshima, Hiroshi Onoda, Takamasa Nukui, Nobuhiro Dougu, Shuji Joho, Yuji Nakatsuji

Author information

Ryoko Shibuya
Department of Neurology, Faculty of Medicine, University of Toyama, Japan
Kousuke Baba
Department of Neurology, Faculty of Medicine, University of Toyama, Japan
Risako Furuta
Department of Neurology, Faculty of Medicine, University of Toyama, Japan
Hiroki Maesaka
Department of Neurology, Faculty of Medicine, University of Toyama, Japan
Hiroaki Hirosawa
Department of Neurology, Faculty of Medicine, University of Toyama, Japan
Tadashi Bando
Department of Surgery, Saiseikai Toyama Hospital, Japan
Akira Oshima
Second Department of Internal Medicine, Faculty of Medicine, University of Toyama, Japan
Hiroshi Onoda
Second Department of Internal Medicine, Faculty of Medicine, University of Toyama, Japan
Takamasa Nukui
Department of Neurology, Faculty of Medicine, University of Toyama, Japan
Nobuhiro Dougu
Department of Neurology, Faculty of Medicine, University of Toyama, Japan
Shuji Joho
Second Department of Internal Medicine, Faculty of Medicine, University of Toyama, Japan
Yuji Nakatsuji
Department of Neurology, Faculty of Medicine, University of Toyama, Japan

Keywords: immune checkpoint inhibitor, myositis symptoms, myasthenia gravis, myocarditis, autoimmune autonomic ganglionopathy, anti-striated muscle antibody

JOURNAL OPEN ACCESS Advance online publication

Article ID: 1801-23

DOI https://doi.org/10.2169/internalmedicine.1801-23

Details

Abstract

An 83-year-old man with hepatocellular carcinoma developed muscle weakness, ptosis, and dyspnea 3 weeks after receiving atezolizumab. Soon after, mechanical ventilation was initiated, which was followed by marked blood pressure spikes. The levels of creatine kinase and troponin-I were significantly elevated, and acetylcholine receptor antibodies were positive. The patient was diagnosed with immune checkpoint inhibitor (ICI)-induced myositis, myasthenia gravis (MG), myocarditis, and suspected autoimmune autonomic ganglionopathy (AAG). After immunotherapy, the serum markers and blood pressure normalized, and he was weaned from the ventilator after five months. To our knowledge, this is the first reported case of AAG secondary to ICI-induced myositis, MG, and myocarditis.

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