LBODP071 Early Detection Of Immune-mediated Hypophysitis With Use Of Checkpoint Inhibitor Immunotherapy

Abstract

Abstract Hypophysitis is an inflammatory infiltration of the pituitary gland. Association with cytotoxic T-lymphocyte antigen 4 (CTLA-4) targeting was described with a recommendation of discontinuing the treatment in such conditions . Hypophysitis has become more prevalent with increased use of immune checkpoint inhibitors with late detection being associated with a high morbidity and mortality. Symptomatic presentation, along with hemodynamic and serum abnormalities warrant urgent intervention as early measures prevent progression. This case is about a 60-year-old female with metastatic renal clear cell carcinoma status post right radical nephrectomy on combined nivolumab and ipilimumab (NIVO/IPI) and history notable for persistent atrial fibrillation on warfarin presented to the hospital after a fall. Eight days after her second cycle on NIVO/IPI, the patient developed hot flashes, vomiting, weakness, and vertiginous symptoms. Her exam was notable for atrial fibrillation with rapid ventricular rate and hypotension. Serology was notable for a sodium of 119 mEq/mL, prompting admission to the hospital. Due to high clinical suspicion for hypophysitis based on serological findings, the patient was given a dose of methylprednisolone then daily hydrocortisone to reverse the pituitary inflammation. Fludrocortisone was started for adrenal insufficiency. MRI of the brain with IV contrast was notable for abnormal enhancement and thickening of the pituitary stalk concerning for hypophysitis. The patient clinically improved with resolution of her dizziness, hot flashes, and vomiting. Her serum sodium improving to 132 mEq/mL. She was discharged home with immunotherapy held. Hypophysitis is a rare inflammatory disease affecting 1 in 7 million. Typical symptoms include headache, vision changes, fatigue, and hypopituitary deficiencies. Reported immunotherapies with incidences of secondary hypophysitis include CTLA-4 and PD-1 therapeutics. Immunotherapy associated hypophysitis occurs in <7% of patients. Hypophysitis is diagnosed by laboratory findings and imaging which can identify this acute process via enhancement and swelling of the pituitary gland . Management modalities include surgery, anti-inflammatory therapy, and conservative therapy. Medical management is mainly directed at the correction of pituitary hormone deficiencies and reduction of pituitary inflammation using glucocorticoid therapy . Presentation: No date and time listed