SHM Converge Scientific Abstract ePoster Gallery-A Trifecta of Havoc: Endocrine Effects of Pembrolizumab

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This case report describes a 44-year-old woman with renal cell carcinoma treated with pembrolizumab who developed multiple immune checkpoint inhibitor-related endocrine complications. After nine months of therapy, she presented with three weeks of anorexia, nausea, vomiting, and diarrhea. Evaluation showed diabetic ketoacidosis, acute kidney injury, severe hyperglycemia, elevated beta-hydroxybutyrate, acidemia, and an anion gap metabolic acidosis. Although the ketoacidosis resolved, her glucose remained very high despite intensive treatment, prompting concern for immune checkpoint inhibitor-induced diabetes (IID).<br /><br />Further workup confirmed insulin deficiency with a low C-peptide level. Additional testing revealed central hypothyroidism, shown by low free T4 with an inappropriately normal TSH, and secondary adrenal insufficiency, supported by a very low morning cortisol and an abnormal ACTH stimulation test. She was discharged on basal and prandial insulin, levothyroxine, and hydrocortisone.<br /><br />The report emphasizes that immune checkpoint inhibitors can cause a range of immune-related adverse events, especially endocrine disorders. While thyroiditis and hypophysitis are more common, IID is an important emerging complication because it can present rapidly and severely, often with diabetic ketoacidosis. Unlike many other immune-related adverse events, IID usually reflects irreversible pancreatic beta-cell destruction and does not respond to steroids. Therefore, treatment requires permanent hormone replacement, most often lifelong insulin.<br /><br />The authors stress the need for a low threshold to recognize checkpoint inhibitor-induced endocrinopathies, especially when patients develop unexplained hyperglycemia or multisystem endocrine abnormalities. Early endocrinology and oncology involvement is essential to prevent life-threatening metabolic crises and to guide ongoing cancer therapy.

Asset Subtitle

Aisha Waquad

Meta Tag

Author List Aanchal Chaudhary, Aisha Waquad, Joel Chittazhattu, Neha Bang, Zia Ur Rehman Durrani

Category Clinical Vignettes

Concept Immune Checkpoint Inhibitor-Induced Diabetes

Concept Pancreatic Beta Cell

Concept Insulin Deficiency

Concept Hyperglycemia

Concept Insulin Replacement

Distinguished Non-Finalist

Presenter Organization University of Oklahoma Medical Center

Presenting Author Aisha Waquad

Track Adult

Keywords

renal cell carcinoma

pembrolizumab

immune checkpoint inhibitor

immune-related endocrinopathy

immune checkpoint inhibitor-induced diabetes

diabetic ketoacidosis

insulin deficiency

central hypothyroidism

secondary adrenal insufficiency

endocrine adverse events

Immune Checkpoint Inhibitor-Induced Diabetes

Pancreatic Beta Cell

Insulin Deficiency

Hyperglycemia

Insulin Replacement