SHM Converge Scientific Abstract ePoster Gallery-A "Shocking" Case of Immune Checkpoint Inhibitor-Associated Primary Adrenal Insufficiency

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An 81-year-old woman with lung adenocarcinoma treated with durvalumab, a PD-L1 immune checkpoint inhibitor, developed recurrent shock, weakness, fatigue, anorexia, vomiting, diarrhea, somnolence, and confusion. She was initially thought to have septic or hypovolemic shock, but no infection was found and her hypotension persisted despite large-volume IV fluids.<br /><br />Further evaluation showed profoundly low cortisol levels on two occasions and markedly elevated ACTH, consistent with primary adrenal insufficiency. Positive 21-hydroxylase antibodies supported an autoimmune adrenalitis diagnosis related to immune checkpoint inhibitor therapy. A recent CT scan showed normal adrenal glands, and her sodium and potassium remained largely normal.<br /><br />She was treated with stress-dose hydrocortisone, starting with 100 mg IV followed by 50 mg IV every 8 hours for one day. This led to rapid and dramatic improvement in blood pressure, mental status, appetite, and overall energy. She was then discharged on oral hydrocortisone replacement: 15 mg in the morning and 5 mg in the afternoon.<br /><br />The case highlights that immune checkpoint inhibitors can cause endocrine immune-related adverse events, including adrenal insufficiency, thyroid disease, diabetes, and hypophysitis. Primary adrenal insufficiency is rare but can be life-threatening and may present as unexplained or recurrent shock. Because it may be mistaken for sepsis or dehydration, clinicians should maintain a high index of suspicion in patients receiving ICIs. Primary adrenal insufficiency may also require mineralocorticoid replacement, unlike secondary adrenal insufficiency. The patient later enrolled in hospice and died about three months after diagnosis.

Asset Subtitle

Deandra K. Chetram

Meta Tag

Author List Deandra K. Chetram, Will M. Schouten

Category Clinical Vignettes

Concept Immune Checkpoint Inhibitor

Concept Primary Adrenal Insufficiency

Concept Adrenal Crisis

Concept Cortisol

Concept ACTH

Distinguished Non-Finalist

Presenter Organization Mayo Clinic Rochester

Presenting Author Deandra K. Chetram

Track Adult

Keywords

durvalumab

PD-L1 inhibitor

primary adrenal insufficiency

immune checkpoint inhibitor

autoimmune adrenalitis

21-hydroxylase antibodies

recurrent shock

hydrocortisone replacement

adrenal crisis

endocrine adverse event

Immune Checkpoint Inhibitor

Primary Adrenal Insufficiency

Adrenal Crisis

Cortisol

ACTH