SHM Converge Scientific Abstract ePoster Gallery-Adrenal Crisis Secondary to Nivolumab Therapy in a 70 Year Old Male

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A 70-year-old man with hypothyroidism and urothelial cancer on nivolumab was admitted for planned TURBT but was found to be acutely confused, aphasic, and unable to provide a history. Initial workup showed severe hyponatremia (Na 116) with otherwise unrevealing urinalysis, chest X-ray, CTA head, and MRI brain. He received hypertonic saline.<br /><br />On hospital day 2, he developed fever, hypotension, and tachycardia, with sodium still low at 120. Blood cultures were drawn, antibiotics started, and he was transferred to the ICU for norepinephrine after fluids failed to improve blood pressure. An AM cortisol was markedly low at 1.0, and thyroid testing showed low-normal TSH with elevated free T4. Stress-dose steroids were started after endocrinology consultation, with subsequent improvement in blood pressure. No infectious source was identified, and antibiotics were later discontinued.<br /><br />The case was concluded to represent adrenal crisis secondary to nivolumab, an immune checkpoint inhibitor. The discussion highlights that endocrine immune-related adverse events are common with ICI therapy, most often affecting the thyroid, pituitary, and adrenal glands. Hypophysitis can cause secondary adrenal insufficiency and other pituitary hormone deficits, while ICIs may also cause primary adrenal insufficiency. Diagnosis may be aided by ACTH stimulation testing, though recent steroid use can confound results. Treatment is steroid replacement, and ICI therapy may sometimes be continued unless symptoms are severe.

Asset Subtitle

Andrew L. Wu

Meta Tag

Author List Andrew L. Wu, Ziad Sad Aldeen

Category Clinical Vignettes

Concept Immune Checkpoint Inhibitor

Concept Secondary Adrenal Insufficiency

Concept Adrenal Crisis

Concept Perioperative Stress-Dose Corticosteroids

Concept Pembrolizumab

Distinguished Non-Finalist

Presenter Organization University of Wisconsin

Presenting Author Andrew L. Wu

Track Adult

Keywords

nivolumab

adrenal crisis

hyponatremia

immune checkpoint inhibitor

secondary adrenal insufficiency

hypophysitis

endocrine immune-related adverse events

cortisol deficiency

thyroid dysfunction

stress-dose steroids

Immune Checkpoint Inhibitor

Secondary Adrenal Insufficiency

Adrenal Crisis

Perioperative Stress-Dose Corticosteroids

Pembrolizumab