A 54-year-old man was admitted to our hospital on August 11th, 2021 due to yellow staining of skin and sclera for 18 days and fever for 3 days. On April 22th, 2021, the color doppler ultrasound revealed pancreatic space-occupying, following this, relevant examinations were performed to confirm the diagnose of pancreatic head cancer, gastric wall invasion, and abdominal lymph node metastasis. From June 2 to June 23th, 2021, the systemic chemotherapy combined with immunotherapy was given to this patient, more specifically: nab-paclitaxel 200mg d1, 8+ Seggio Capsules 60mg bid d1-14, sintilimab 200mg d1/3w were injected for this combined treatment. His liver function was normal before treatment. On July 5th, 2021, the patient developed a scattered rash all over the body, which was diagnosed as immune-related dermatitis. This symptom of the patient was improved after a hormone therapy. On July 25th, 2021, fatigue, anorexia, and yellowing of the skin and sclera were observed in the patient. The patient had fever on August 8th, with a body temperature of up to 39 C and without cough, expectoration, dysuria, urgency, abdominal pain, and diarrhea. The antibiotic and glucocorticoid (2 mg/kg/d) treatment for the patient lasted 3 days, resulting in a disatisfactory treatment effect. Afterwards, the patient was admitted to the hospital for further diagnosis and treatment. He had no history of hypertension, diabetes, heart disease, blood transfusion, and drug allergy. Physical examination: the sclera and skin of the whole body were severe yellow staining, scattered erythema and papules, and no liver palm and spider nevus were observed.; the breath sounds of both lungs were clear, with the absence of wet or dry sounds; the heart sounded strong, with a regular rthythm of a heart rate of 68 beats/min; the abdomen was soft, with the absence of tenderness and rebound tenderness; the liver and spleen were not under the ribs; no percussion pain in the liver area was observed, and mobility dullness was negative; no edema was noted on either leg.
Laboratory examinations showed the following results: Whole blood cell analysis: WBC:11.2x109/L, NEUT#:8.68x109/L, PLT:43x109/L; Coagulation: PT:29.3s, INR:2.74, PTA:26%, APTT:35.7s; Blood biochemical examination: ALT:1736.4IU/L, AST:800IU/L, TBil:167mumol/L, DBil:98.8mumol/L, D/T:0.59, gamma-GT:256.7IU/L, ALP:102.2IU/L; HBsAg, HBeAg, HBcAg, HBsAb, HBeAb, HBcAb, Hepatitis A antibody, Hepatitis C antibody and Hepatitis E antibody IgM were all negative. AFP: 5.8ng/mL; autoantibodies were negative; Immunoglobulin IgG10.8g/L, IgA 3.84g/L, IgM0.73g/L. Abdominal MRI (September 10th, 2021): cystic mass in the neck of the pancreas with nodules on the right wall. Liver puncture was not performed for the patient due to coagulation dysfunction. Final diagnosis: Immune-related liver injury induced by ICIs, grade 4, with a subacute liver failure, early. The diagnosis basis of this patient is shown in  Table 1 .
Then, Sindilizumab was stopped immediately, intravenous magnesium isoglycyrrhizinate 200mg once a day, AdenosylMethionine 1g once a day and glucocorticoid (2mg/kg/d) were given. And on August 13th, 16th, and 18th, the single-level plasma exchange (PE) treatment was performed respecitively, and the dose of each treatment was the same, namely 2000ml fresh frozen plasma. Liver function and coagulation indicators were improved significantly after this treatment (see  Figures 1A, B ). Afterwards, sintilimab was discontinued, and systemic chemotherapy was used for 3 cycles, the liver function was normal during this period of treatment. Repeat abdominal MRI on December 9th: the size of cystic mass in the neck of the pancreas was smaller than that observed on September 10th, 2021 (see  Figures 1C, D ).