Endocrine Abstracts

Introduction: Dual nivolumab and ipilimumab immunotherapy has the potential of causing an immune-mediated thyrotoxicosis, precipitating thyroid storm.

Case details: A 62-year-old Caucasian woman with a history of Lung Carcinoma (Non small Cell Lung Carcinoma) presented to the emergency department, with a 3-day history of intractable nausea, severe headache, vomiting and anxiety.

She had been initiated on dual nivolumab and ipilimumab therapy 6 weeks prior and received two courses of therapy thus far. Her last dose was 10 days prior to presentation.

Past medical history

a. Hypertension.

b. Depression.

c. Osteoarthritis.

d. Newly diagnosed Lung Carcinoma (NSCLC).

Investigations

• CXR-No evidence of consolidation/Pulmonary Oedema.

• Blood Cultures-Negative.

• Urine dip-Negative.

• Bloods- Revealed Leucocytosis, elevated CRP levels.

• CT Head-Nil evidence of Intracranial haemorrhage/SOL.

• Lumbar puncture-was performed and resultant Gram stain, culture, cell count, protein and glucose were all normal.

• TSH- <0.001 (0.4–4.0 mU/l).

• FT4–36.2 pmol/l (9.0–25.0 pmol/l).

• FT3–9.8 pmol/l (3.5–7.8 pmol/l).

• Thyroid peroxidase and thyroid stimulating immunoglobulin levels were within normal range.

• Scoring systems- Burch- Wartofsky Score- 55 – indicative of Thyroid storm.

Management

• Beta-blockers: propranolol 1–2 mg intravenously or 40–80 mg per os every 8 h is the drug of choice because, on the one hand, contrasts the increased binding of catecholamine to beta-adrenergic receptors, on the other hand, reduces the T4 to T3 peripheral deiodination.

• Thyrostatics: methimazole 15–20 mg every 6 h or propylthiouracil with a loading dose of 500–1000 mg followed by 250 mg every 4 h. It should be mentioned that rectal administration of both methimazole and propylthyouracyle is allowed, at a dose of 400–600 mg every 6 h and 20–40 mg every 8–6 h, respectively.

• Large iodine amount: Lugol solution or saturated potassium iodide solution (or sodium iodide 500–1000 mg daily intravenously inhibits thyroid hormone leakage by the thyroid gland. Iodine should be administered not sooner than 1 h after anti-thyroid drug administration.

• Glucocorticoids: hydrocortisone 100 mg intravenously every 6–8 h reduces the T4 to T3 peripheral deiodination

Summary

• Thyroid function tests and thyroid symptoms should be monitored in patients with undergoing nivolumab and ipilimumab immunotherapy

• Prompt treatment of thyroid storm is potentially life-saving. Close monitoring in an inpatient setting in addition to treatment with β-blockers, antithyroid agents, steroids and bile sequestering therapies are recommended.

• Thyroid storm is a clinical diagnosis, usage of Scoring tools-Burch-Wartofsky score and the Japanese Thyroid Association Scoring System recommended.

• Thyroid function tests and thyroid symptoms should be monitored in patients with undergoing nivolumab and ipilimumab immunotherapy

• Prompt treatment of thyroid storm is potentially life-saving. Close monitoring in an inpatient setting in addition to treatment with β-blockers, antithyroid agents, steroids and bile sequestering therapies are recommended.

• Thyroid storm is a clinical diagnosis, usage of Scoring tools-Burch--Wartofsky score and the Japanese Thyroid Association Scoring System recommended.