Critical Care: Student/Resident Case Report Poster - Critical Care I |

Where Is the Storm Coming From: A Case of Thyroid Storm Secondary to Ipilimumab FREE TO VIEW

Faiza Ferdousy, MD; Christopher Caesar Williams, MD; Benjamin Sherman, MD; Brian Fouty, MD; Mary Vu, MD
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University of South Alabama, College of Medicine, Mobile, AL

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):379A. doi:10.1016/j.chest.2016.08.392
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Checkpoint inhibitor immunotherapy is related to rare immune related adverse events. We present a very rare case of thyroid storm after treatment with ipilimumab in our ICU. To our knowledge this is the second case of thyroid storm reported due to ipilimumab.

CASE PRESENTATION: A 49-year-old white male with Stage 3C metastatic melanoma presented with altered mental status, fever, palpitations, and diarrhea. Patient was treated with ipilimuab for the melanoma with the most recent dose received 3 weeks ago. He was treated for meningitis with broad spectrum antibiotics, but did not show much clinical improvement, and required mechanical ventilation for worsening mental status and inability to protect his airway. A thorough investigation for infectious and autoimmune causes was negative. He was persistently tachycardic in the 160s and also developed new onset systolic heart failure. Thyroid function studies showed TSH <0.01 micro IU/ml (normal 0.3-4.7), T3 of 22 pg/ml (normal 2.4-4.2), and free T4 level of 5 ng/dl (normal 0.7-1.6). Based on the Burch and Wartofsky scoring system, the patient was diagnosed with thyroid storm most likely due to ipilimumab. He was treated with hydrocortisone equivalent to prednisone 1 mg/kg, propylthiouricil, Lugol's solution, and betablockers, and responded well to the treatment. He was extubated with gradual improvement of his mental status.

DISCUSSION: Ipilimumab is a recombinant human monoclonal antibody to the cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4). Blocking CTLA-4 enhances antitumor immunity by promoting T-cell activation and cytotoxic T-lymphocyte proliferation. This induction of a tolerance break against the tumor may be responsible for adverse events. Ipilimumab has been associated with a wide spectrum of thyroid function abnormalities, most commonly thyroiditis and/or hypothyroidism in 1-2% of patients. Having a clinical suspicion for thyroid storm can be very challenging since the findings are non-specific and often misdiagnosed as sepsis. While the Burch and Wartofsky scoring system can be used to diagnose thyroid storm, no standardized, universally accepted clinical tools for diagnosis exist. Treatment includes steroids, antithyroid drugs and betablockers. It is recommended to check thyroid function tests before initiating ipilimumab and every three months or sooner if the patient develops symptoms.

CONCLUSIONS: It is important to have a very high clincal suspicion for unusual side effects secondary to checkpoint inhibitor therapy. While ipilimuab usually causes other forms of endocrinopathies, clinicians should inlcude thyroid storm in their differential diagnosis in the appropriate clincal setting.

Reference #1: A Novel Melanoma Therapy Stirs Up a Storm: Ipilimuab-Induced Thyrotoxicosis Christine Yu et al, Endocrinology, Diabetes and Metabolism, February 2015.

Reference #2: Immune Related Adverse Events Associated with Anti-CTLA-4 Antibodies: Systematic Review and Meta-analysis Anne Bernard et al, BMC Medicine, 2015.

DISCLOSURE: The following authors have nothing to disclose: Faiza Ferdousy, Christopher Caesar Williams, Benjamin Sherman, Brian Fouty, Mary Vu

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