SHM Converge Scientific Abstract ePoster Gallery-Cancer, Multiple Endocrinopathies, and Andrenal Insufficiency: A Diagnostic Challenge

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This case report describes a 41-year-old man with metastatic squamous cell lung cancer treated with paclitaxel/carboplatin and the immune checkpoint inhibitors nivolumab and ipilimumab. He initially presented with palpitations, tachycardia, nausea, abdominal pain, and anorexia. Imaging showed a lung mass, pulmonary nodules, and a left adrenal mass. His thyroid studies revealed marked thyrotoxicosis (low TSH, elevated free T4 and T3), and he was diagnosed with immunotherapy-induced hyperthyroidism and discharged on methimazole.<br /><br />Two days later, he returned with worsening lethargy, nausea, vomiting, severe hypotension (80/40 mm Hg), and tachycardia. Laboratory testing showed a very low morning cortisol, and cosyntropin testing confirmed adrenal insufficiency. Low ACTH suggested secondary adrenal insufficiency, likely due to immune-related hypophysitis, though the adrenal mass also raised concern for primary adrenal involvement. He improved rapidly after receiving intravenous hydrocortisone and fluids.<br /><br />The report emphasizes that cancer patients often have nonspecific symptoms such as fatigue, anorexia, nausea, and hypotension, which can obscure adrenal crisis. Immune checkpoint inhibitors can cause multiple endocrine toxicities, including thyroiditis, hyperthyroidism, hypophysitis, and primary adrenal insufficiency. In this patient, thyrotoxicosis and adrenal insufficiency together likely contributed to the crisis.<br /><br />The main takeaway is that adrenal crisis should remain in the differential diagnosis for cancer patients—especially those receiving immunotherapy—who present with shock-like symptoms. Prompt recognition and treatment with stress-dose glucocorticoids can be lifesaving.

Asset Subtitle

Nasser Rizvi

Meta Tag

Author List George W. Garriss III, Nasser Rizvi, Usha Anand

Category Clinical Vignettes

Concept Adrenal Crisis

Concept Adrenal Insufficiency

Concept Immune Checkpoint Inhibitor

Concept Primary Adrenal Insufficiency

Concept Secondary Adrenal Insufficiency

Distinguished Non-Finalist

Presenter Organization Wellstar - Kennestone Hospital

Presenting Author Nasser Rizvi

Track Adult

Keywords

metastatic squamous cell lung cancer

immune checkpoint inhibitors

nivolumab

ipilimumab

thyrotoxicosis

hyperthyroidism

adrenal insufficiency

hypophysitis

adrenal crisis

hydrocortisone

Adrenal Crisis

Adrenal Insufficiency

Immune Checkpoint Inhibitor

Primary Adrenal Insufficiency

Secondary Adrenal Insufficiency