A case with a primary adrenal insufficiency secondary to nivolumab

Abstract

Immunological therapy in treatment of lung cancer has been introduced effectively. Nivolumab that is anti PD-1 monoclonal antibody has some immunological side effects. 50 years old male was diagnosed stage IV adenocarcinoma with bilaterally adrenal metastasis. The driver mutations (EGFR, ALK, ROS-1) were not detected. He had been treated with 3 lines chemotherapies. He had not responded any chemotherapy. We started nivolumab in the patient. After 10 days from the first therapy, he admitted to Emergency Unit of our hospital with dyspnea, nausea, vomiting, and changes of consciousness. Arterial blood pressure (80/50 mmHg) and randomized blood sugar (60 mg/dl) was low. He had dry mucosa and hyperpigmentation on his skin. We found Urea:93 mg/dl (>50), Creatinin:2.11 mg/dl (>1.5), Sodium:124 mEq/L (<135), Potassium:6.7 mEq/L (>5) in his blood and pH:7.23, pCO2:34.8, HCO3:14.2 (<22) in arterial blood gases. We thought metabolic alkalosis secondary to hyperkalemia and adrenal insufficiency. Adrenocorticothrophic hormone (ACTH) level was 1234 (>50), cortizol level (at 08:00 AM) 0.96 mcg/dl (<10). In Cranial MR, there was no any acute pathology. In abdomen ultrasound, there was no any finding of adrenal bleeding or infection. The diagnosis of primary adrenal insufficiency was thought to be related with immunological side effect of nivolumab. The patient has been treated with intravenous steroid replacement. After the treatment, levels of sodium, potassium, ACTH, blood sugar and blood pressure has been normalized. We have presented a case with primary adrenal insufficiency secondary to nivolumab, as a very rare immunological side effect of this new drug.