- A 24 Year Old Caucasian Woman With A History Of Metastatic Melanoma Presented To The Emergency Department With A 3 Day 1 (87.26 KiB) Viewed 27 times
- A 24 Year Old Caucasian Woman With A History Of Metastatic Melanoma Presented To The Emergency Department With A 3 Day 2 (79.24 KiB) Viewed 27 times
A 24-year-old Caucasian woman with a history of metastatic melanoma presented to the emergency department, with a 3-day history of intractable nausea, vomiting and anxiety. She had been initiated on dual nivolumab and ipilimumab therapy 1 month prior and received two courses of therapy thus far. Her last dose was 1 week prior to presentation. She had previously completed 1 year of high-dose interferon therapy. Surgical history included right video-assisted thoracoscopic surgery with right lower lobe wedge resection due to metastasis 6 weeks prior and right cheek melanoma resection 2 years prior. Medical history included depression and anxiety. The patient's medications included atenolol, citalopram and alprazolam. She denied alcohol or illicit drug use. On presentation, she was febrile to 40.3°C (104.5° Fahrenheit), tachycardic to 146 bpm, and agitated with symptoms of nausea and vomiting. Her blood pressure was stable at 138/87. Her Glasgow coma scale was 15. On examination, the patient was agitated and acutely anxious but still awake, alert and oriented. She was diaphoretic and flushed with no jugular venous distention, no. peripheral oedema, and with regular rate and rhythm on cardiac examination, and clear breath sounds on lung examination. The rest of the physical examination was unremarkable. Most notably, neither thyromegaly, nor exophthalmos, nor tender thyroid was appreciable on physical examination. On the Burch et al diagnostic point scale for thyroid storm, our patient scored 85. By this scoring system, a score higher than 45 is suggestive of thyroid storm. The patient was admitted to the intensive care unit (ICU), with endocrinology and oncology consultation. Go to:
Discussion Go to: This case report is an example of dual nivolumab and ipilimumab immunotherapy causing an immune-mediated thyrotoxicosis, precipitating thyroid storm. Thyroid storm is a clinical diagnosis, but the point scale system developed by Burch et al can aid in confirming the diagnosis. This scale system assigns points in the categories of thermoregulatory dysfunction, central nervous system effects, gastrointestinal-hepatic dysfunction, cardiovascular dysfunction and precipitant history. Scores are totalled and a score of 45 or greater is highly suggestive of thyroid storm. Our patient's score totalled 85 on initial presentation and 65 on readmission. It is important to point out that our patient was treated with interferon for 1 year prior to the initiation of nivolumab and ipilimumab. Interferon has also been implicated in causing thyroid dysfunction. However, our patient had thyroid function testing that was within normal range prior to the initiation of nivolumab and ipilimumab. A database search for 'nivolumab and ipilimumab thyrotoxicosis' revealed one case report where ipilimumab alone caused thyroid storm in a patient receiving immunotherapy for melanoma. In that case, antithyroid medications were started with resolution of symptoms. Steroids were considered, but not started because of oncologic concern for reversal effects of the patient's immunotherapy. COL Ha