Koshy, Sharmila C, MD

Magdaleno, Angela, DO

Scurozo, Joseph, DO

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of MedicineImmune Related Adverse Events: Isolated ACTHDeficiency with Nivolumab/ IpilimumabCombination TherapyJoseph Scurozo DOLehigh Valley Health Network, joseph.scuorzo@lvhn.orgAngela Magdaleno DOLehigh Valley Health Network, angela.magdaleno@lvhn.orgSharmila C. Koshy MDLehigh Valley Health Network, Sharmila_C.Koshy@lvhn.orgFollow this and additional works at: https://scholarlyworks.lvhn.org/medicinePart of the Endocrinology, Diabetes, and Metabolism Commons, and the Internal MedicineCommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtScurozo, J. Magdaleno, A. Koshy, S. (2018, November 10th). Immune Related Adverse Events: Isolated ACTH Deficiency with Nivolumab/Ipilimumab Combination Therapy. Poster Presented at: (ACP) American College of Physicians Regional Conference, Scranton, PA.Magdaleno, A. Scuorzo, J. Koshy, S. (2019, March 24). Immune Related Adverse Events: Isolated ACTH Deficiency with Nivolumab/Ipilimumab Combination Therapy. Poster Presented at: The Endocrine Society Conference, New Orleans, LA.© 2018 Lehigh Valley Health NetworkImmune Related Adverse Events:  Isolated ACTH Deficiency with Nivolumab/Ipilimumab Combination Therapy Joseph Scuorzo, DO, Angela Magdaleno, DO, Sharmila Koshy, MD Lehigh Valley Health Network, Allentown, Pa.INTRODUCTION•  Immunotherapies have become revolutionary treatment modalities for several malignancies including patients with advanced melanoma and non-small cell lung carcinoma.•  New immunotherapy treatments can result in unique adverse events due to increased inflammation in any organ in the body. Common immune-related adverse events include vitiligo, colitis, hepatitis, pneumonitis, and endocrinopathies, most commonly thyroiditis. CASE PRESENTATION•  A 77-year-old male with metastatic choroidal melanoma treated with 2 cycles of Ipilimumab and Nivolumab presented to the hospital with complaints of generalized weakness, malaise, loss of appetite and 20 lb. weight loss over a two-week period. •  His concerns were initially attributed to progression of his known malignancy, however he developed further symptoms of intermittent fevers with eosinophilic leukocytosis, hypotension, disorientation, lethargy, tremors, incoherent speech, and urinary incontinence. •  Further work-up with MRI brain showed no new metastases or abnormalities and EEG was without epileptic foci. Infectious workup was unrevealing except for a questionable right lower lobe infiltrate on chest x-ray, which was subsequently treated with antibiotics. CT chest/abdomen/pelvis showed pulmonary metastases without further abnormalities. •  With symptoms concerning for possible adrenal insuffi-ciency, a random cortisol was checked resulting at 1.7 ug/dL. Adrenocorticotropic hormone (ACTH) stimulation test confirmed the diagnosis of adrenal insufficiency  with the highest resultant level of 9.3 ug/dL. A low  ACTH level of <5 confirmed the diagnosis of secondary adrenal  insufficiency.•  Treatment was initiated with methylprednisolone 60mg  intravenously every 12 hours with concern for auto-immune hypophysitis related to immunotherapy.  Symptoms began improving rapidly with steroid initiation. •  Further Endocrine evaluation revealed mild TSH elevation but otherwise normal FSH, LH, Prolactin, and insulin growth factor-1. DISCUSSION•  This case uniquely exhibits immunotherapy induced  isolated ACTH deficiency, rather than hypophysitis.  Hypo physitis can occur with an adverse event rate up  to 17% while on Ipilimumab, however isolated ACTH  deficiency is rarer. •  Diagnosis is challenging with symptomatology mimicking common malignancy complaints. It is important for all physicians to be able to recognize symptoms of secondary adrenal insufficiency, especially as a side effect of immu-notherapy, as this condition is life threatening and requires immediate diagnosis and treatment. 

Immune Related Adverse Events: Isolated ACTH Deficiency with Nivolumab/ Ipilimumab Combination Therapy

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=2639&context=medicine

Immune Related Adverse Events: Isolated ACTH Deficiency with Nivolumab/ Ipilimumab Combination Therapy

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