AN UNUSUAL SEPSIS MIMIC: CENTRAL ADRENAL INSUFFICIENCY DUE TO IMMUNE CHECKPOINT INHIBITOR-INDUCED HYPOPHYSITIS

Abstract

CASE PRESENTATION: 72 year old female non-smoker with a past medical history of metastatic papillary thyroid cancer with lung metastases on nivolumab/ipilimumab (last treated 2 months prior to admission), who initially presented to a community hospital with nausea, vomiting, and weakness. She developed fevers and fluid-refractory shock. She was treated with broad spectrum antibiotics for possible sepsis and subsequently transferred to a tertiary care center. On transfer, she was afebrile, required moderate doses of norepinephrine, and was mildly hypoxemic and lethargic on exam. White blood cell count was normal. A random cortisol was low at 3 ug/dL. Subsequent cosyntropin stimulation test resulted in a minimal increase in serum cortisol to 9.6 ug/dL, consistent with adrenal insufficiency. She was initiated on stress-dose steroids and vasopressors were subsequently weaned off within twenty-four hours. Further laboratory workup demonstrated low ACTH, FSH, LH, and IGF-1 levels and elevated prolactin. Computed tomography of the chest, abdomen, and pelvis was notable for new bilateral pulmonary infiltrates and known lung metastases. Blood and respiratory cultures and viral tests were negative. Magnetic resonance imaging of the brain showed a partially empty sella with no evidence of mass lesions.