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• W2894956230 abstract "SESSION TITLE: Critical Care 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Lymphocytic or autoimmune hypophysitis is a rare, potentially fatal complication of immune checkpoint inhibitor therapy in cancer treatment. Early recognition is essential to proper management of affected patients. We present a case of a 65-year-old male undergoing adjuvant melanoma treatment with ipilimumab, hospitalized for suspected sepsis and ultimately diagnosed with immune-mediated hypophysitis. CASE PRESENTATION: A 65-year-old male with stage IIIC malignant melanoma of the scalp treated with adjuvant ipilimumab presented to the emergency department with altered mental status, fever of 103.1F, heart rate 102 bpm, and a known MRSA-infected scalp wound. Patient was admitted under sepsis criteria for management with IV fluids and antibiotics. Work-up revealed a two week history of progressive fatigue, anorexia, and acute renal injury. Due to concern for immune mediated hypophysitis high dose corticosteroid therapy was initiated with methylprednisolone 2 mg/kg in divided doses. MRI of the brain demonstrated enlargement of the anterior pituitary gland. TSH was low at 0.05 uIU/ml; free thyroxine was 0.5 ng/dL, warranting initiation of levothyroxine. Patient's mental status returned to baseline within 12 hours of receiving corticosteroid therapy. Near complete resolution of symptoms was achieved within 3 days and he was discharged home on a steroid taper. DISCUSSION: Immune checkpoint inhibitors including ipilimumab, pembrolizumab, and nivolumab treat many different cancers by mobilizing the immune system against malignant tumor cells. Autoimmune complications include type I diabetes, pneumonitis, colitis, hepatitis, nephritis, and pancreatitis. Ipilimumab, a monoclonal antibody that binds cytotoxic T-lymphocyte associated antigen-4, promotes the cytotoxic activity of T-lymphocytes. It is indicated for treatment of metastatic melanoma and adjuvant treatment of stage III malignant melanoma. Autoimmune hypophysitis is a rare, potentially fatal complication that must be recognized and corrected promptly. Incidence is highest with ipilimumab, occurring in 3.2% of patients, who typically present with fatigue and headache. Other symptoms may include anorexia, encephalopathy, and temperature dysregulation. Pituitary enlargement on MRI and low levels of pituitary hormones are diagnostic. Mainstays of therapy are hormone replacement and methylprednisolone 1-2 mg/kg IV in divided doses until improvement is achieved, followed by steroid taper. Most patients regain full pituitary function. Multiple autoimmune complications of checkpoint inhibitors can develop concurrently with hypophysitis. CONCLUSIONS: Use of immunotherapy is increasing in frequency as indications expand. Autoimmune hypophysitis is one potentially life-threatening complication of therapy which can present with physiologic signs of sepsis. Physicians in both inpatient and outpatient settings must maintain a low threshold of suspicion. Reference #1: Romualdo Barroso-Sousa, William T. Barry, Ana C. Garrido-Castro, F. Stephen Hodi, Le Min, Ian E. Krop, Sara M. Tolaney. Incidence of Endocrine Dysfunction Following the Use of Different Immune Checkpoint Inhibitor Regimens; A Systematic Review and Meta-analysis. JAMA Oncol. Published online September 28, 2017. https://doi.org/10.1001/jamaoncol.2017.3064 Reference #2: Alexander T. Faje, Ryan Sullivan, Donald Lawrence, Nicholas A. Tritos, Riley Fadden, Anne Klibanski, Lisa Nachtigall; Ipilimumab-Induced Hypophysitis: A Detailed Longitudinal Analysis in a Large Cohort of Patients With Metastatic Melanoma, The Journal of Clinical Endocrinology & Metabolism, Volume 99, Issue 11, 1 November 2014, Pages 4078–4085, https://doi.org/10.1210/jc.2014-2306 Reference #3: Ryder M, Callahan M, Postow MA, Wolchok J, Fagin JA. Endocrine-related adverse events following ipilimumab in patients with advanced melanoma: a comprehensive retrospective review from a single institution. Endocrine-related cancer. 2014;21(2):371-381. https://doi.org/10.1530/ERC-13-0499. DISCLOSURES: No relevant relationships by Haytham Adada, source=Web Response No relevant relationships by Mahmoud Amarna, source=Web Response no disclosure on file for Camelia Circulescu; No relevant relationships by Ayan Novruzov, source=Web Response No relevant relationships by Lydia Novruzov, source=Web Response" @default.
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• W2894956230 date "2018-10-01" @default.
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• W2894956230 title "LYMPHOCYTIC HYPOPHYSITIS PRESENTING AS SEPSIS" @default.
• W2894956230 doi "https://doi.org/10.1016/j.chest.2018.08.326" @default.
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