Abstract
The advent of immune checkpoint inhibitors has significantly improved the prognosis of patients with advanced malignancies. As we begin to understand these medications, multiple immune-related adverse effects (irAEs) have been found with these drugs, including endocrinopathies. Understanding the treatment-related adverse events of these medications is critical for clinical practice. Thyroid-related adverse effects usually occur within the first three months of treatment and rarely after eight months. It can manifest as an early onset of thyrotoxicosis, which is largely asymptomatic, followed by a rapid transition to hypothyroidism, requiring long-term levothyroxine substitution. We present a case in which our patient was found unresponsive, hypothermic, and with respiratory failure almost after completing a year of treatment with pembrolizumab. He had an initial mild elevation in thyroid-stimulating hormone (TSH) of 6.52, although with normal free thyroxine (T4) of 1.06, in his first three months of starting treatment which then rapidly progressed to a true myxedema coma. The infrequency with which this occurs makes it a diagnostic challenge.
Highlights
Myxedema coma is defined as severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs
We report a case of myxedema coma in a patient who presented at a very advanced stage while being on therapy with pembrolizumab. e increased immune response induced by the immune checkpoint inhibitors like pembrolizumab leads to immune-related adverse effects (irAEs), some of which are usually irreversible. e mechanism of thyroid-related adverse effects is still unclear and appears independent of thyroid autoantibodies but may include T cells, natural killer cells, and/or monocyte-mediated pathways and are frequently associated with anti-PD1 antibodies [1–5]
Myxedema coma is a rare presentation in current times given easy accessibility of thyroid-stimulating hormone (TSH) testing
Summary
Myxedema coma is defined as severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs. It is a medical emergency with high mortality rate. It is a rare presentation, likely due to the widespread availability of TSH assays, which allows practitioners to monitor their patients’ hormonal balance closely. We report a case of myxedema coma in a patient who presented at a very advanced stage while being on therapy with pembrolizumab. E increased immune response induced by the immune checkpoint inhibitors like pembrolizumab leads to irAEs, some of which are usually irreversible. We report a case of myxedema coma in a patient who presented at a very advanced stage while being on therapy with pembrolizumab. e increased immune response induced by the immune checkpoint inhibitors like pembrolizumab leads to irAEs, some of which are usually irreversible. e mechanism of thyroid-related adverse effects is still unclear and appears independent of thyroid autoantibodies but may include T cells, natural killer cells, and/or monocyte-mediated pathways and are frequently associated with anti-PD1 antibodies [1–5]
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