Myxoedema coma caused by immunotherapy-related thyroiditis and enteritis
Thyroid dysfunction is among the most common immune-related adverse reactions associated with immune checkpoint inhibitors. It most commonly manifests as painless thyroiditis followed by permanent hypothyroidism. This usually causes mild toxicity that does not interfere with oncological treatment. I...
| Main Authors: | , , , , |
|---|---|
| Format: | Article |
| Language: | English |
| Published: |
Bioscientifica
2021-10-01
|
| Series: | Endocrinology, Diabetes & Metabolism Case Reports |
| Online Access: | https://edm.bioscientifica.com/view/journals/edm/2021/1/EDM21-0130.xml |
| _version_ | 1818606398627381248 |
|---|---|
| author | Darran Mc Donald Eirena Goulden Garret Cullen John Crown Rachel K Crowley |
| author_facet | Darran Mc Donald Eirena Goulden Garret Cullen John Crown Rachel K Crowley |
| author_sort | Darran Mc Donald |
| collection | DOAJ |
| description | Thyroid dysfunction is among the most common immune-related adverse reactions associated with immune checkpoint inhibitors. It most commonly manifests as painless thyroiditis followed by permanent hypothyroidism. This usually causes mild toxicity that does not interfere with oncological treatment. In rare instances, however, a life-threatening form of decompensated hypothyroidism called myxoedema coma may develop. We present a case of myxoedema coma in a woman in her sixties who was treated with a combination of CTLA-4 and PD-1 immune checkpoint inhibitors; for stage four malignant melanoma. She became hypothyroid and required thyroxine replacement after an episode of painless thyroiditis. Six months after the initial diagnosis of malignant melanoma, she presented to the emergency department with abdominal pain, profuse diarrhoea, lethargy and confusion. She was drowsy, hypotensive with a BP of 60/40 mmHg, hyponatraemic and hypoglycaemic. Thyroid function tests (TFTs) indicated profound hypothyroidism with a TSH of 19 mIU/L, and undetectable fT3 and fT4, despite the patient being compliant with thyroxine. She was diagnosed with a myxoedema coma caused by immune-related enteritis and subsequent thyroxine malabsorption. The patient was treated with i.v. triiodothyronine (T3) and methylprednisolone in the ICU. While her clinical status improved with T3 replacement, her enteritis was refractory to steroid therapy. A thyroxine absorption test confirmed persistent malabsorption. Attempts to revert to oral thyroxine were unsuccessful. Unfortunately, the patient’s malignant melanoma progressed significantly and she passed away four months later. This is the first reported case of myxoedema coma that resulted from two distinct immune-related adverse reactions, namely painless thyroiditis and enterocolitis. |
| first_indexed | 2024-12-16T14:10:14Z |
| format | Article |
| id | doaj.art-a8782f670e944570ab43bf3926267c00 |
| institution | Directory Open Access Journal |
| issn | 2052-0573 |
| language | English |
| last_indexed | 2024-12-16T14:10:14Z |
| publishDate | 2021-10-01 |
| publisher | Bioscientifica |
| record_format | Article |
| series | Endocrinology, Diabetes & Metabolism Case Reports |
| spelling | doaj.art-a8782f670e944570ab43bf3926267c002022-12-21T22:28:48ZengBioscientificaEndocrinology, Diabetes & Metabolism Case Reports2052-05732021-10-01111510.1530/EDM-21-0130Myxoedema coma caused by immunotherapy-related thyroiditis and enteritisDarran Mc Donald0Eirena Goulden1Garret Cullen2John Crown3Rachel K Crowley4Department of EndocrinologyDepartment of EndocrinologyDepartment of GastroenterologyDepartment of Oncology, St Vincent’s University Hospital, Dublin, Ireland; Department of Medicine, University College Dublin, Dublin, IrelandDepartment of Endocrinology; Department of Medicine, University College Dublin, Dublin, IrelandThyroid dysfunction is among the most common immune-related adverse reactions associated with immune checkpoint inhibitors. It most commonly manifests as painless thyroiditis followed by permanent hypothyroidism. This usually causes mild toxicity that does not interfere with oncological treatment. In rare instances, however, a life-threatening form of decompensated hypothyroidism called myxoedema coma may develop. We present a case of myxoedema coma in a woman in her sixties who was treated with a combination of CTLA-4 and PD-1 immune checkpoint inhibitors; for stage four malignant melanoma. She became hypothyroid and required thyroxine replacement after an episode of painless thyroiditis. Six months after the initial diagnosis of malignant melanoma, she presented to the emergency department with abdominal pain, profuse diarrhoea, lethargy and confusion. She was drowsy, hypotensive with a BP of 60/40 mmHg, hyponatraemic and hypoglycaemic. Thyroid function tests (TFTs) indicated profound hypothyroidism with a TSH of 19 mIU/L, and undetectable fT3 and fT4, despite the patient being compliant with thyroxine. She was diagnosed with a myxoedema coma caused by immune-related enteritis and subsequent thyroxine malabsorption. The patient was treated with i.v. triiodothyronine (T3) and methylprednisolone in the ICU. While her clinical status improved with T3 replacement, her enteritis was refractory to steroid therapy. A thyroxine absorption test confirmed persistent malabsorption. Attempts to revert to oral thyroxine were unsuccessful. Unfortunately, the patient’s malignant melanoma progressed significantly and she passed away four months later. This is the first reported case of myxoedema coma that resulted from two distinct immune-related adverse reactions, namely painless thyroiditis and enterocolitis.https://edm.bioscientifica.com/view/journals/edm/2021/1/EDM21-0130.xml |
| spellingShingle | Darran Mc Donald Eirena Goulden Garret Cullen John Crown Rachel K Crowley Myxoedema coma caused by immunotherapy-related thyroiditis and enteritis Endocrinology, Diabetes & Metabolism Case Reports |
| title | Myxoedema coma caused by immunotherapy-related thyroiditis and enteritis |
| title_full | Myxoedema coma caused by immunotherapy-related thyroiditis and enteritis |
| title_fullStr | Myxoedema coma caused by immunotherapy-related thyroiditis and enteritis |
| title_full_unstemmed | Myxoedema coma caused by immunotherapy-related thyroiditis and enteritis |
| title_short | Myxoedema coma caused by immunotherapy-related thyroiditis and enteritis |
| title_sort | myxoedema coma caused by immunotherapy related thyroiditis and enteritis |
| url | https://edm.bioscientifica.com/view/journals/edm/2021/1/EDM21-0130.xml |
| work_keys_str_mv | AT darranmcdonald myxoedemacomacausedbyimmunotherapyrelatedthyroiditisandenteritis AT eirenagoulden myxoedemacomacausedbyimmunotherapyrelatedthyroiditisandenteritis AT garretcullen myxoedemacomacausedbyimmunotherapyrelatedthyroiditisandenteritis AT johncrown myxoedemacomacausedbyimmunotherapyrelatedthyroiditisandenteritis AT rachelkcrowley myxoedemacomacausedbyimmunotherapyrelatedthyroiditisandenteritis |