Fushuang Ha,1– 4,* Haoyu Wang,1– 4,* Junjun Cai,1– 4 Jing Liang,1– 4 Hua Liu1– 4 

1Hepatology and Gastroenterology Department, The Third Central Hospital of Tianjin, Tianjin, People’s Republic of China; 2Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, People’s Republic of China; 3Artificial Cell Engineering Technology Research Center, Tianjin, People’s Republic of China; 4Tianjin Institute of Hepatobiliary Disease, Tianjin, People’s Republic of China

*These authors contributed equally to this work

Correspondence: Hua Liu, Email dishu@yeah.net

Abstract: We describe the case of an older male patient with hepatocellular carcinoma and a history of hepatitis B virus-related cirrhosis and type 2 diabetes mellitus. At 12 weeks after treatment with transcatheter arterial chemoembolization (TACE) combined with systemic therapy using lenvatinib and camrelizumab, the patient was found to have progressive disease, based on the modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria. He also exhibited symptoms such as left eyelid ptosis and limitations in inward, upward, and downward movements of the left eye. The possibility of immune checkpoint inhibitor-induced myasthenia gravis was considered. After relevant examinations including electromyography and repetitive nerve stimulation, a diagnosis of oculomotor nerve palsy induced by diabetes-related microvascular dysfunction was ultimately considered. Subsequently, the patient was treated with camrelizumab combined with regorafenib and TACE therapy and was concurrently subjected to stricter glycemic control and neurotrophic treatment. Three months later, the ocular symptoms disappeared, and the mRECIST assessment revealed the achievement of a partial response. At the time of manuscript submission, the overall survival of the patient had reached 81 months.

Keywords: immunotherapy, hepatocellular carcinoma, checkpoint inhibitor, immune adverse event, myasthenia gravis, oculomotor paralysis, diabetes mellitus