Endocrine Abstracts

Introduction: Endocrine dysfunctions are a well known side effect of Immunotherapy with check point inhibitors. Endocrine dysfunction can begin as early as 6 days post initiation of therapy. There is a growing consensus that prompt recognition and early management of these endocrinopathies is essential; however there is a lack of specific guidelines regarding the monitoring of endocrine function. We present a case report of an asymptomatic patient known to have renal cell cancer who presented with multiple endocrine abnormalities which were incidentally diagnosed.

Case Prsentation: A 43 year old gentleman was admitted with seizures. He was on ipilimumab and nivolumab for metastatic renal cell cancer, the first dose of which had been initiated 43 days ago and the second dose 14 days ago. He had no symptom of any endocrine dysfunction. His BP was 90/40 mm Hg. Routine evaluation showed ACTH deficiency (ACTH 6 pmol/l), low cortisol levels (41 nmol/l) along with low testosterone (7.7 nmol/l) low normal IGF-1 levels (7 nmol/l). Patient also had hyperthyroidism (TSH:0.09mIu/l, T3:6.6 pmol/l T4: 30 pmol/l) which on thyroid uptake scan was found to be secondary to thyroiditis. Seizures were found to be secondary to multiple brain metastasis. His blood pressure responded to cortisol replacement therapy. Unfortunately, due to rapid progression of the disease, he was put on palliative pathway and discharged with comfort care.

Discussion: The society for endocrinology clinical committee has recently endorsed a comprehensive management plan for the acute presentations of endocrinopathies post immunotherapy. However, to the best of our knowledge, no guidelines are there to help come to a diagnosis before the endocrine dysfunction have begun to manifest clinically. As the endocrinopathies can progress silently, suddenly manifesting with a catastrophic event, there is an urgent need to establish guidelines regarding the initiation and frequency of endocrine testing.