SHM Converge Scientific Abstract ePoster Gallery-Pembrolizumab-Induced Adrenal Insufficiency Masked as Failure to Thrive

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This case describes a 73-year-old woman with metastatic endometrial adenocarcinoma who developed 6 weeks of fatigue, myalgias, nausea, and vomiting after receiving five cycles of pembrolizumab, which had been stopped because of a rash. On presentation, she was hypotensive, dehydrated, and appeared clinically unwell. Initial supportive care did not improve her condition.<br /><br />Further evaluation showed euvolemic hypotonic hyponatremia, prompting endocrine consultation. Her symptoms and lab findings raised concern for pembrolizumab-induced adrenal insufficiency, specifically secondary adrenal insufficiency due to isolated ACTH deficiency. Abdominal imaging showed stable metastatic disease, making cancer progression less likely as the cause of her decline.<br /><br />She was treated with hydrocortisone, with rapid improvement in symptoms within 24 hours. She was discharged on a taper to lifelong maintenance steroid replacement.<br /><br />The report emphasizes that immune checkpoint inhibitors such as pembrolizumab can cause rare but serious endocrine immune-related adverse events. Adrenal insufficiency may present nonspecifically as “failure to thrive,” fatigue, nausea, or vomiting, and may be missed without a careful medication history. This diagnosis should be considered in patients with prior anti-PD1 therapy who present with signs of adrenal dysfunction, especially when accompanied by hyponatremia and hypotension.<br /><br />Key lessons include recognizing the importance of reviewing immunotherapy exposure in hospitalized patients, identifying clinical features of new-onset adrenal insufficiency, and obtaining timely endocrine input. Early treatment can prevent progression to adrenal crisis and usually has a good prognosis with steroid replacement.

Asset Subtitle

Joleigh v. Ferro

Meta Tag

Author List Geeda M. Maddaleni MD, Joleigh v. Ferro

Category Clinical Vignettes

Concept Pembrolizumab

Concept Secondary Adrenal Insufficiency

Concept Adrenal Insufficiency

Concept Glucocorticoid Replacement

Concept Immune Checkpoint Inhibitor

Distinguished Non-Finalist

Presenter Organization UMass Chan School of Medicine

Presenting Author Joleigh v. Ferro

Track Adult

Keywords

pembrolizumab

adrenal insufficiency

isolated ACTH deficiency

hyponatremia

hypotension

immune checkpoint inhibitor

endocrine irAE

fatigue

hydrocortisone

metastatic endometrial adenocarcinoma

Pembrolizumab

Secondary Adrenal Insufficiency

Adrenal Insufficiency

Glucocorticoid Replacement

Immune Checkpoint Inhibitor