Endocrine Abstracts

A 24 year old man was admitted by the Surgeons with left sided abdominal pain. He was febrile and tachycardic and found to have raised inflammatory markers. Abdominal CT scan revealed a 6 cm left adrenal haemorrhage with no evidence of an underlying lesion. Initial endocrine investigations were unremarkable for Cushings, Conn’s and adrenal insufficiency. Norepinephrine levels were high but settled subsequently. He had a coagulopathy and evidence of reactivation of EB virus.

He had a past history of Multiple sclerosis treated eighteen months previously with Alemtuzumab.

He remained febrile and developed acute kidney injury. His symptoms and signs fitted the criteria for haemophagocytic lymphohistiocytosis (HLH), confirmed on bone marrow biopsy. His coagulopathy was due to antibodies to factor VIII (acquired haemophilia) and he developed autoimmune thyroiditis requiring Thyroxine replacement. His HLH was successfully treated with steroids and Rituximab.

We think Alemtuzumab treatment had induced the autoimmune disorders (his coagulopathy and thyroid disease), as well as reactivating EB virus. The combination of coagulopathy and EB viral infection may have caused his adrenal haemorrhage.

Endocrinologists should be aware of the wide spectrum of autoimmune disorders that can be precipitated by monoclonal antibody treatment.