SHM Converge Scientific Abstract ePoster Gallery-Nivolumab Induced Hypophysitis in Renal Cell Carcinoma

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This case describes a 68-year-old man with stage IV renal cell carcinoma on maintenance nivolumab who presented with declining mental status, hypotension, and respiratory distress after home oxycodone use. In the emergency setting, his blood pressure was 80/50 mmHg and oxygen saturation was 83% on room air. Naloxone produced immediate improvement in alertness, blood pressure, and breathing, so he was admitted on a Narcan drip. His home Lasix was stopped and he received IV fluids, but his mental status did not continue to improve. On hospital day 1, he developed worsening respiratory distress from fluid overload, prompting a rapid response. Further evaluation on hospital day 2 revealed acute encephalopathy due to central adrenal insufficiency, hypothyroidism, and hypogonadotropism, consistent with nivolumab-induced hypophysitis. Laboratory findings supported pituitary dysfunction, including low ACTH, very low AM cortisol, low FSH/LH, and low TSH. Brain MRI showed only mild flattening of the pituitary without a mass or clear enlargement.<br /><br />He was treated with hydrocortisone 50 mg every 8 hours, with continued levothyroxine. By hospital day 3, his mental status and creatinine returned to baseline. He was discharged on hydrocortisone 50 mg twice daily and continued levothyroxine.<br /><br />The report emphasizes that immune checkpoint inhibitors such as nivolumab can cause hypophysitis weeks to months after treatment. Presentation may be nonspecific and can mimic opioid toxicity, sepsis, or other causes of encephalopathy, respiratory depression, and hemodynamic instability. Importantly, imaging may not show pituitary enlargement. Clinicians should consider endocrine testing in patients receiving checkpoint inhibitors when standard treatments do not fully explain or resolve symptoms, because prompt recognition and steroid replacement can be lifesaving.

Asset Subtitle

Erin M. Eidsness

Meta Tag

Author List Abhishek Matta, Erin M. Eidsness

Category Clinical Vignettes

Concept Nivolumab

Concept Immune Checkpoint Inhibitor

Concept Hypophysitis

Concept Secondary Adrenal Insufficiency

Concept Central Adrenal Insufficiency

Distinguished Non-Finalist

Presenter Organization University of North Dakota School of Medicine

Presenting Author Erin M. Eidsness

Track Adult

Keywords

nivolumab

hypophysitis

adrenal insufficiency

checkpoint inhibitor

encephalopathy

opioid toxicity

hypotension

respiratory distress

pituitary dysfunction

hydrocortisone

Nivolumab

Immune Checkpoint Inhibitor

Hypophysitis

Secondary Adrenal Insufficiency

Central Adrenal Insufficiency