ABSTRACT
OBJECTIVE: Widespread use of immune checkpoint inhibitors (ICIs) in cancer treatment has led to an increase in the number of reported cases of immunotherapy-related endocrinopathies. This study aimed to analyze and compare human leukocyte antigen (HLA) signatures associated with ICI-induced type 1 diabetes (ICI-T1D) and isolated adrenocorticotropic hormone deficiency (ICI-IAD) in patients with both conditions. METHODS: HLA signatures were examined for their frequencies of occurrence in 22 patients with ICI-T1D without concurrent IAD, including 16 patients from nationwide reports (ICI-T1D group) and 14 patients with ICI-IAD without concurrent T1D (ICI-IAD group). The HLA signatures were also compared for their respective frequencies in 11 patients with ICI-T1D and ICI-IAD, including eight from nationwide reports (ICI-T1D/IAD group). RESULTS: In the ICI-T1D group, HLA-DRB1*09:01-DQB1*03:03 and DQA1*03:02, which are in linkage disequilibrium with DRB1*09:01-DQB1*03:03 and DRB1*13:02-DQB1*06:04, were susceptible to ICI-T1D, whereas DRB1*15:02-DQB1*06:01 was protective against ICI-T1D. In the ICI-IAD group, DPB1*09:01, C*12:02-B*52:01, and DRB1*15:02-DRB1*06:01, which are in strong linkage disequilibrium, were associated with susceptibility to ICI-IAD. Moreover, DRB1*15:02-DRB1*06:01 was not detected in the ICI-T1D/IAD group. CONCLUSIONS: This study revealed specific HLA signatures associated with ICI-T1D and ICI-IAD. Moreover, HLA-DRB1*15:02-DRB1*06:01, an ICI-IAD-susceptible HLA haplotype, coincides with the ICI-T1D-protective HLA haplotype, suggesting that the presence of DRB1*15:02-DRB1*06:01 may protect against the co-occurrence of T1D in patients with ICI-IAD.
Subject(s)
Adrenocorticotropic Hormone , Diabetes Mellitus, Type 1 , Humans , Diabetes Mellitus, Type 1/genetics , Diabetes Mellitus, Type 1/drug therapy , Adrenocorticotropic Hormone/deficiency , Immune Checkpoint Inhibitors/adverse effects , Male , Female , HLA Antigens/genetics , Adrenal Insufficiency/genetics , Adrenal Insufficiency/chemically induced , Adult , Middle Aged , Neoplasms/drug therapy , Endocrine System Diseases , Hypoglycemia , Genetic Diseases, InbornABSTRACT
Hypopituitarism is a relatively rare complication of hemorrhagic fever with renal syndrome. However, almost all available reported cases were total anterior pituitary hypofunction, isolated growth-hormone deficiency, or isolated gonadotropin deficiency. Here, we firstly describe a patient with partial hypopituitarism with ACTH deficiency as the main manifestation as a complication of hemorrhagic fever with renal syndrome.
Subject(s)
Hemorrhagic Fever with Renal Syndrome , Hypopituitarism , Humans , Adrenal Insufficiency , Adrenocorticotropic Hormone/deficiency , Adrenocorticotropic Hormone/blood , Hemorrhagic Fever with Renal Syndrome/complications , Hemorrhagic Fever with Renal Syndrome/diagnosis , Hypopituitarism/etiology , Hypopituitarism/diagnosis , Hypopituitarism/complications , PrognosisABSTRACT
OBJECTIVE: We aimed to elucidate the clinical features of pituitary immune-related adverse events (irAEs) induced by PD-1 inhibitors in a Chinese cohort and the previous literatures. PATIENTS AND DESIGN AND MEASUREMENTS: We retrospectively analysed the clinical manifestations, laboratory examination findings, imaging features and treatments of 14 patients with pituitary irAEs caused by PD-1 inhibitors in our cohort. In addition, we searched PubMed for all English articles on pituitary irAEs induced by PD-1 inhibitors published from 1950 to 2023. A total of 47 articles were included, and the clinical characteristics of 94 patients with pituitary irAEs induced by PD-1 inhibitors in these literatures were compared to the characteristics of our cohort. RESULTS: Among the 14 patients in our cohort with pituitary irAEs induced by PD-1 inhibitors, 12 patients (85.71%, 12/14) exhibited isolated ACTH deficiency (IAD), 100.0% (14/14) of the central adrenocortical insufficiency, and 2 patients showed more than one hypothalamic-pituitary axis injury (14.29%, 2/14). Pituitary magnetic resonance imaging in all the 14 patients showed no pituitary enlargement. In previous studies we reviewed, 82.98% of the total (78/94) presented with pituitary irAEs as IAD, 100.0% (94/94) of the central adrenocortical insufficiency, and 78.33% of the patients showed no abnormality of the pituitary gland (47/60). The pituitary irAEs caused by PD-1 inhibitors did not involve typical manifestations of hypophysitis, such as pituitary enlargement, headache, visual field defects, and multiple pituitary function impairments in our cohort and the previous literatures. CONCLUSION: In our study, pituitary immune-related adverse reactions induced by PD-1 inhibitors mainly manifested isolated ACTH deficiency rather than hypophysitis.
Subject(s)
Hypophysitis , Immune Checkpoint Inhibitors , Pituitary Gland , Programmed Cell Death 1 Receptor , Humans , Hypophysitis/chemically induced , Middle Aged , Retrospective Studies , Female , Male , Adult , Immune Checkpoint Inhibitors/adverse effects , Programmed Cell Death 1 Receptor/antagonists & inhibitors , Aged , Pituitary Gland/immunology , Pituitary Gland/pathology , Pituitary Diseases/chemically induced , Pituitary Diseases/immunology , Magnetic Resonance Imaging , Adrenal Insufficiency/chemically induced , Adrenocorticotropic Hormone/deficiency , Endocrine System Diseases , Hypoglycemia , Genetic Diseases, InbornABSTRACT
Coronavirus disease 2019 (COVID-19) due to a severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection can include various systemic organ disorders including endocrinopathies and neurological manifestations. We report the case of a 65-year-old Japanese man who developed isolated adrenocorticotropic hormone (ACTH) deficiency and encephalopathy following SARS-CoV-2 infection. Two weeks after his COVID-19 diagnosis, he was emergently admitted to our hospital because of subacute-onset delirium. On admission, he presented hyponatremia (128 mEq/L) and secondary adrenal insufficiency (ACTH <1.5 pg/mL, cortisol 0.53 µg/dL). Brain imaging and laboratory examinations including SARS-CoV-2 polymerase chain reaction testing in the cerebrospinal fluid revealed no abnormalities. His consciousness level worsened despite the amelioration of hyponatremia by intravenous hydrocortisone (100 mg/day), but his neurological presentations completely resolved after three consecutive days of high-dose (400 mg/day) hydrocortisone. His encephalopathy did not deteriorate during hydrocortisone tapering. He continued 15 mg/day hydrocortisone after discharge. His encephalopathy might have developed via a disturbance of the autoimmune system, or a metabolic effect associated with adrenal insufficiency, although the time lag between the hyponatremia's improvement and the patient's neurological response to the steroid was incompatible with common cases of delirium concurrent with adrenal insufficiency. At 13 months after his hospitalization, the patient's neurological symptoms have not recurred and he has no endocrinological dysfunctions other than the remaining ACTH deficiency. A thorough consideration of the immunological and metabolic characteristics of SARS-CoV-2 is advisable when clinicians treat patients during and even after their COVID-19 disease period.
Subject(s)
Adrenal Insufficiency , Adrenocorticotropic Hormone/deficiency , Brain Diseases , COVID-19 , Delirium , Endocrine System Diseases , Genetic Diseases, Inborn , Hypoglycemia , Hyponatremia , Male , Humans , Aged , Hydrocortisone/therapeutic use , COVID-19/complications , COVID-19 Testing , Hyponatremia/complications , SARS-CoV-2 , Adrenal Insufficiency/complications , Adrenal Insufficiency/drug therapy , Brain Diseases/etiology , Brain Diseases/complications , Delirium/etiology , Delirium/complicationsABSTRACT
Deficient anterior pituitary with common variable immune deficiency (DAVID) syndrome is a rare condition characterized by adrenocorticotropic hormone (ACTH) deficiency and primary hypogammaglobulinemia. It is due to heterozygous mutations of the nuclear factor kappa-B subunit 2 (NFKB2) gene. Only a few isolated cases have been reported since its first description by our team. Through the international multicenter GENHYPOPIT network, we identified a new case of DAVID syndrome. We then conducted an extensive review of the DAVID syndrome cases published from 2012 to 2022. A 7-year-old boy was diagnosed with symptomatic hypoglycemia revealing ACTH deficiency. Laboratory tests showed asymptomatic hypogammaglobulinemia. He harbored a heterozygous point mutation in NFKB2 gene (c.2600C > T, p.Ala867Val). His management included hydrocortisone replacement treatment, and he also received subcutaneous immunoglobulins during the Covid-19 pandemic. We analyzed 28 cases of DAVID syndrome with ACTH deficiency. ACTH deficiency was the only hormone deficiency in 79% of patients, but some patients harbored growth hormone (GH) and thyroid stimulating hormone (TSH) deficiencies. The first presenting symptoms were sinus/pulmonary infections (82%, mean age of 3 years) and alopecia (mean age of 4.7 years). ACTH deficiency was the third presenting condition (mean age at diagnosis of 8.6 years). All patients had hypogammaglobulinemia (decreased IgA and IgM levels), and 57% of patients had at least one autoimmune manifestation. Heterozygous mutations at the 3'end of the NFKB2 gene, coding for the C-terminal domain of the protein, were identified in all cases. Better knowledge of DAVID syndrome will help clinicians make an early diagnosis to avoid life-threatening complications.
Subject(s)
Common Variable Immunodeficiency , Pituitary Hormones, Anterior , Adult , Child , Female , Humans , Male , Adrenocorticotropic Hormone/deficiency , Agammaglobulinemia/complications , Autoimmunity , Common Variable Immunodeficiency/complications , Common Variable Immunodeficiency/genetics , Common Variable Immunodeficiency/immunology , Common Variable Immunodeficiency/physiopathology , Heterozygote , Human Growth Hormone/deficiency , Infections/complications , Mothers , Mutation , Phenotype , Pituitary Hormones, Anterior/deficiency , Syndrome , Thyrotropin/deficiencyABSTRACT
BACKGROUND: Several immune checkpoint inhibitors have been implemented for cancer treatment which have shown some degree of antitumor effcacy, while immune-related adverse events (irAEs) that affect multiple organ functions ensue which obviously should not be neglected. Though less common than other kinds of irAEs, Immune checkpoint inhibitors (ICIs) related Isolated ACTH deficiency (IAD) may cause long-term damage to pituitary-adrenal axis. Several case reports are available about IAD during anti-PD-1 therapy. We report the first case of immune checkpoint inhibitor-induced IAD following 3 month of sintilimab therapy. CASE PRESENTATION: A 66-year-old Chinese man was diagnosed with stage IIIB lung adenocarcinoma with involving ipsilateral intrapulmonary and hilar lymph node metastasis. After 3 months of combination therapy of nedaplatin, pemetrexed and sintilimab, the patient presented with general fatigue, nausea and vomiting. Laboratory investigation at admission revealed hyponatremia and hypokalemia. Further investigation revealed adrenocorticotropic hormone and cortisol levels were far below than normal limits. His other pituitary hormone levels were normal, except for mild elevation of follicle stimulating hormone and estradiol. Cranic magnetic resonance imaging showed a normal pituitary gland. Isolated adrenocorticotropic hormone deficiency was diagnosed, and corticosteroid replacement therapy was administered, leading to a significant improvement of his symptoms while ACTH level maintaining low level. CONCLUSIONS: Our patient developed isolated ACTH deficiency during combination cancer treatment with chemotherapy and sintilimab. Although isolated ACTH deficiency due to anti-PD-1 including sintilimab therapy is rare occurrence, it can often cause severe clinical symptoms. Its diagnosis basically relies on clinical symptoms and endocrinological examination. Unlike traditional hypophysitis diagnosed by cranial MRI, pituitary MRI of IAD due to anti-PD-1 often indicates normal pituitary gland implying that over-reliance on imaging findings is not recommended. Even if clinical symptoms have relieved after corticosteroid replacement therapy was commenced, low levels of ACTH or cortisol could maintain for a long period which highlights the need for long term corticosteroid therapy. The purpose of the current report was to provide increased awareness of early detection and therapy of IAD.
Subject(s)
Adenocarcinoma of Lung , Lung Neoplasms , Adenocarcinoma of Lung/drug therapy , Adrenal Insufficiency , Adrenocorticotropic Hormone/deficiency , Aged , Antibodies, Monoclonal, Humanized , Endocrine System Diseases , Estradiol , Follicle Stimulating Hormone , Genetic Diseases, Inborn , Humans , Hydrocortisone , Hypoglycemia , Immune Checkpoint Inhibitors , Lung Neoplasms/complications , Lung Neoplasms/drug therapy , Male , PemetrexedABSTRACT
Isolated adrenocorticotropic hormone (ACTH) deficiency (IAD) is a rare pituitary disorder characterized by decreased secretion of ACTH, leading to cortisol deficiency, with normal secretion of other pituitary hormones. Diagnostics remains a challenge due to variable and nonspecific clinical presentation: weakness, weight loss, and low blood pressure. Hyponatremia and anemia are typical abnormalities in basic laboratory tests. Diagnostic procedures for IAD are based on results of low morning cortisol with low/normal ACTH concentrations, with flat response of these hormones in dynamic tests [with insulin/glucagon/corticotropin-releasing hormone (CRH)]. There is also no cortisol response to Synacthen during the standard (not extended) test duration. Several aetiologies lead to the development of IAD. The congenital form is typical of childhood onset. In adults, autoimmune aetiology prevails, including lymphocytic hypophysitis, and rarer - pituitary injury or other lesions in the gland. IAD has recently been demonstrated as a complication in patients receiving therapy with immune checkpoint inhibitors. Also, in the case of IAD, paraneoplastic autoimmune hypophysitis should be considered. Next, alcohol abuse has been reported to be a reason of IAD in single cases. Treatment with oral hydrocortisone usually causes significant improvement. As an example, we present 2 patients diagnosed with IAD. Both were older males, with history of alcohol abuse, long lasting hyponatremia, and weakness. Their clinical state normalized after receiving replacement therapy with hydrocortisone.
Subject(s)
Alcoholism , Hyponatremia , Pituitary Diseases , Adrenocorticotropic Hormone/deficiency , Adult , Alcoholism/drug therapy , Endocrine System Diseases , Genetic Diseases, Inborn , Humans , Hydrocortisone/therapeutic use , Hypoglycemia , Hyponatremia/drug therapy , Hyponatremia/etiology , MaleABSTRACT
A 65-year-old man was admitted to our hospital with a 6-year history of painful muscle stiffness in his trunk and lower limbs, preventing him from walking. Stiff-person syndrome (SPS) was diagnosed because the patient had symptoms of painful muscle spasms elicited by tactile stimulation without joint contracture. Although SPS- related autoantibodies in the serum, including anti-glycine R, anti-amphiphysin, anti-glutamic acid decarboxylase (GAD), anti-dipeptidyl peptidase-like protein (DPPX) and anti-γ-aminobutyric acid-A (GABAA) R, were negative, the ACTH and cortisol levels were low. On the basis of additional loading tests for anterior pituitary function and ACTH, isolated ACTH deficiency (IAD) was diagnosed. Hormonal replacement therapy with hydrocortisone at 15 mg/day ameliorated the condition quickly, and the patient became asymptomatic after three months. Flexion contractures have been reported as musculoskeletal symptoms of IAD, but are not usually evident in patients with SPS. The present case illustrates that the painful muscle spasms elicited by tactile stimulation without joint contracture characteristic of SPS can also be symptoms of IAD.
Subject(s)
Contracture , Stiff-Person Syndrome , Adrenocorticotropic Hormone/deficiency , Aged , Aminobutyrates , Autoantibodies , Endocrine System Diseases , Genetic Diseases, Inborn , Glutamate Decarboxylase , Humans , Hydrocortisone , Hypoglycemia , Male , Peptide Hydrolases , Spasm/diagnosis , Spasm/drug therapy , Spasm/etiology , Stiff-Person Syndrome/diagnosis , Stiff-Person Syndrome/drug therapy , gamma-Aminobutyric AcidABSTRACT
BACKGROUND: The global COVID-19 pandemic requires urgent development of new vaccines. Endocrinological adverse effects following the new mRNA vaccine against COVID-19 have been reported in several cases. Specific to the involvement of pituitary function; however, only a single case with hypophysis has been reported. This is the first case of isolated adrenocorticotropic hormone (ACTH) deficiency (IAD) following mRNA vaccination against COVID-19. CASE PRESENTATION: A healthy 31-year-old man received the BNT162b2 SARS-CoV-2 mRNA vaccine. The first injection was uneventful. One day after the second injection, he noticed general fatigue and fever. In the following several days, he additionally developed headaches, nausea, and diarrhea. Four days after the vaccine injection, he visited a hospital with worsening of these symptoms. Physical examination revealed slight disorientation but no other deficits. Laboratory tests revealed hyponatremia, hypoglycemia, and extremely low plasma ACTH and serum cortisol levels (ACTH < 1.5 pg/ml, cortisol 1.6 µg/dl). He was diagnosed with adrenal crisis and was emergently treated with hydrocortisone. The symptoms responded well and he recovered within a few days. Magnetic resonance images after the replacement with hydrocortisone revealed an atrophic pituitary gland. The patient was referred to our tertiary hospital for further endocrinological examination. Pituitary endocrine load tests revealed isolated adrenocortical response deficiency. After other clinical assessments, he was diagnosed as having isolated ACTH deficiency. After initiation of hydrocortisone replacement, there has been no recurrence of symptoms related to adrenocortical insufficiency nor involvement of other pituitary functions. CONCLUSION: This is the first reported case of IAD potentially associated with COVID-19 immunization. Recent reports have emphasized the importance of adjuvants in the mRNA vaccine that induce the endocrinological adverse effects through disturbance of the autoimmune system, but details are still unclear. Given the broad and rapid spread of vaccinations against COVID-19, it is clinically important to consider that there could be cases with a rare but emergent adrenal crisis even among those who present common symptoms of adverse effects following inactive SARS-CoV-2 mRNA vaccination.
Subject(s)
Adrenal Insufficiency , Adrenocorticotropic Hormone , BNT162 Vaccine , COVID-19 , Endocrine System Diseases , Hypoglycemia , Adrenal Insufficiency/chemically induced , Adrenal Insufficiency/drug therapy , Adrenocorticotropic Hormone/deficiency , Adult , BNT162 Vaccine/adverse effects , COVID-19/prevention & control , Endocrine System Diseases/chemically induced , Endocrine System Diseases/drug therapy , Humans , Hydrocortisone/blood , Hydrocortisone/therapeutic use , Hypoglycemia/chemically induced , Hypoglycemia/drug therapy , Male , SARS-CoV-2 , Vaccination/adverse effectsABSTRACT
Hypertension guidelines recommend measuring blood pressure (BP) in both arms at least once. However, this is seldom done due to uncertainties regarding measurement procedure and the implications of finding a clinically important inter-arm BP difference (IAD). This study aimed to provide insight into the prevalence of clinically important IADs in a large Indian primary care cohort. A number of 134 678 (37% female) unselected Indian primary care participants, mean age 45.2 (SD 11.9) years, had BP measured in both arms using a standardized, triplicate, automated simultaneous measurement method (Microlife WatchBP Office Afib). On average, there were clinically minor differences in right and left arm BP values: systolic BP 134.4 vs 134.2 mmHg (p < .01) and diastolic BP 82.7 vs 82.6 mmHg (p < .01), respectively. Prevalence of significant mean systolic IAD between 10 and 15 mmHg was 7,813 (5.8%). Systolic IAD ≥ 15 mmHg 2,980 (2.2%) and diastolic IAD ≥ 10 mmHg 7,151 (5.3%). In total, there were 7,595 (5.6%) and 8,548 (6.3%) participants with BP above the 140/90 mmHg threshold in only the left or right arm, respectively. Prevalence of participants with elevated BP on one arm only was highest in patients with a systolic IAD ≥ 15 mmHg; 19.1% and 13.7%, for left and right arm, respectively. This study shows that a substantial prevalence of IAD exists in Indian primary care patients. BP is above the diagnostic threshold for hypertension in one arm only for 6% of participants. These findings emphasize the importance of undertaking bilateral BP measurement in routine clinical practice.
Subject(s)
Hypertension , Adrenocorticotropic Hormone/deficiency , Blood Pressure/physiology , Blood Pressure Determination/methods , Endocrine System Diseases , Female , Genetic Diseases, Inborn , Humans , Hypertension/diagnosis , Hypertension/epidemiology , Hypoglycemia , Male , Middle Aged , Prevalence , Primary Health CareABSTRACT
PURPOSE: Isolated adrenocorticotropic hormone deficiency is a rare disease; however, since immune check point inhibitors (ICIs) have become widely used, many more cases have been reported. In this study, we compared the human leukocyte antigen (HLA) signatures between ICI-induced isolated adrenocorticotropic hormone deficiency (IAD) and idiopathic IAD (IIAD). DESIGN AND METHODS: Clinical features and HLA frequencies were compared among 13 patients with ICI-induced IAD, 8 patients with IIAD, and healthy controls. HLA frequencies of healthy controls were adopted from a HLA database of Japanese population. RESULTS: Age and body mass index were higher, while the rate of weight loss was lower, in patients with ICI-induced IAD than in those with IIAD. No HLA alleles had a significantly higher frequency in patients with ICI-induced IAD than in healthy controls, whereas the frequencies of HLA-DRB1*09:01, HLA-DQA1*03:02, and DQB1*03:03 were significantly higher in patients with IIAD than in healthy controls. CONCLUSIONS: ICI-induced IAD and IIAD were different in terms of HLA frequencies. There were no specific HLAs related to ICI-induced IAD, whereas several HLAs in strong linkage disequilibrium were associated with IIAD. This might suggest that the two diseases have different pathological mechanisms. HLAs unique to IIAD may be helpful in predicting its pathophysiology.
Subject(s)
Adrenocorticotropic Hormone , Immune Checkpoint Inhibitors , Adrenal Insufficiency , Adrenocorticotropic Hormone/deficiency , Alleles , Endocrine System Diseases , Gene Frequency , Genetic Diseases, Inborn , Humans , HypoglycemiaABSTRACT
Kallmann syndrome (KS) is an uncommon genetic disorder characterized by isolated congenital hypogonadotropic hypogonadism (CHH) and anosmia/hyposmia. KS originates from abnormal embryonic migration of olfactory axons and gonadotropin-releasing hormone (GnRH)-synthesizing neurons. It can be challenging to diagnose due to its heterogeneous clinical presentation and genes implied. Herein, we report a rare phenotype of KS in two sisters accompanied by a variety of nonreproductive disorders such as hypoparathyroidism, hypercortisolism, atrophy of the cerebellum, intellectual disability, and remarkably, ovarian dysgenesis. Additionally, both subjects present muscle weakness, exercise intolerance, marked hypotonia and seizures, being suspected, although not fully confirmed, mitochondrial encephalomyopathy. These cases illustrate the heterogeneous clinical presentation and the diagnostic difficulties often found in patients suffering from this condition. These clinical features have never been described before as associated with KS; therefore, we decided to report this novel KS phenotype.
Subject(s)
Gonadal Dysgenesis , Hypogonadism , Kallmann Syndrome , Adrenocorticotropic Hormone/deficiency , Endocrine System Diseases , Genetic Diseases, Inborn , Gonadotropin-Releasing Hormone/genetics , Humans , Hypoglycemia , Hypogonadism/congenital , Hypogonadism/diagnosis , Hypogonadism/genetics , Kallmann Syndrome/complications , Kallmann Syndrome/diagnosis , Kallmann Syndrome/genetics , Mutation , PhenotypeABSTRACT
Autoimmune polyendocrine syndrome (APS) is one of the life-threatening immune-related adverse events (irAEs). We firstly report a case of APS induced by adjuvant nivolumab therapy. Clinicians should be aware of the potential risks of developing severe irAEs when applying adjuvant immunotherapy.
Subject(s)
Diabetes Mellitus, Type 1 , Polyendocrinopathies, Autoimmune , Thyroid Diseases , Adrenocorticotropic Hormone/adverse effects , Adrenocorticotropic Hormone/deficiency , Diabetes Mellitus, Type 1/chemically induced , Diabetes Mellitus, Type 1/drug therapy , Endocrine System Diseases , Genetic Diseases, Inborn , Humans , Hypoglycemia , Nivolumab/adverse effects , Polyendocrinopathies, Autoimmune/chemically induced , Thyroid Diseases/chemically inducedABSTRACT
Pituitary autoimmunity is one of the principal causes of hypopituitarism. Additionally, hypophysitis is one of the immune-related adverse events associated with immunotherapy. Recent case-oriented research has revealed a novel type of autoimmune hypophysitis, anti-PIT-1 hypophysitis, related to isolated adrenocorticotropic hormone (ACTH) deficiency and immune checkpoint inhibitor-related hypophysitis, as a form of paraneoplastic syndrome. Under these conditions, the ectopic expression of pituitary antigens present in tumors evokes a breakdown of immune tolerance, resulting in the production of autoantibodies and autoreactive cytotoxic T cells that specifically harm pituitary cells. Consequently, an innovative clinical entity of paraneoplastic autoimmune hypophysitis has been purported. This novel concept and its underlying mechanisms provide clues for understanding the pathogenesis of autoimmune pituitary diseases and can be applied to other autoimmune diseases. This review discusses the etiology of paraneoplastic autoimmune hypophysitis and its future.
Subject(s)
Autoimmune Diseases , Autoimmune Hypophysitis , Hypophysitis , Pituitary Diseases , Adrenocorticotropic Hormone/deficiency , Autoantibodies , Endocrine System Diseases , Genetic Diseases, Inborn , Humans , Hypoglycemia , Hypophysitis/etiology , Pituitary Diseases/etiologyABSTRACT
Central adrenal insufficiency (AI) due to isolated adrenocorticotropic hormone (ACTH) deficiency (IAD) has been recently associated with immune checkpoint inhibitor (ICI) therapy. Our aim was to analyze the prevalence, clinical characteristics, and therapeutic outcomes in cancer patients with IAD induced by ICI therapy. A retrospective and multicenter study was performed. From a total of 4447 cancer patients treated with ICI antibodies, 37 (0.8%) (23 men (62.2%), mean age 64.7 ± 8.3 years (range 46-79 years)) were diagnosed with IAD. The tumor most frequently related to IAD was lung cancer (n = 20, 54.1%), followed by melanoma (n = 8, 21.6%). The most common ICI antibody inhibitors reported were nivolumab (n = 18, 48.6%), pembrolizumab (n = 16, 43.2%), and ipilimumab (n = 8, 21.6%). About half of the patients (n = 19, 51.4%) had other immune-related adverse events, mainly endocrine adverse effects (n = 10, 27.0%). IAD was diagnosed at a median time of 7.0 months (IQR, 5-12) after starting immunotherapy. The main reported symptom at presentation was fatigue (97.3%), followed by anorexia (81.8%) and general malaise (81.1%). Mean follow-up time since IAD diagnosis was 15.2 ± 12.5 months (range 0.3-55 months). At last visit, all patients continued with hormonal deficiency of ACTH. Median overall survival since IAD diagnosis was 6.0 months. In conclusion, IAD is a rare but a well-established complication associated with ICI therapy in cancer patients. It develops around 7 months after starting the treatment, mainly anti-PD1 antibodies. Recovery of the corticotropic axis function should not be expected.
Subject(s)
Melanoma , Nivolumab , Adrenocorticotropic Hormone/deficiency , Aged , Endocrine System Diseases , Genetic Diseases, Inborn , Humans , Hypoglycemia , Immunotherapy/adverse effects , Ipilimumab/adverse effects , Male , Melanoma/drug therapy , Middle Aged , Nivolumab/adverse effects , Retrospective StudiesABSTRACT
Recently, immune checkpoint inhibitors have been drawing much attention as cancer immunotherapy, but it has been shown that various immune-related adverse events (irAEs) are induced by immune checkpoint inhibitors in various organs, which has become one of the serious issues at present. A 58-year-old Japanese male with malignant melanoma was treated with nivolumab and/or ipilimumab. During the period of treatment, he suffered from various irAEs. Firstly, about 1 month after starting nivolumab monotherapy, destructive thyroiditis was induced, and so we started replacement therapy with levothyroxine. Secondly, about 1 month after starting nivolumab and ipilimumab combination therapy, aseptic meningitis was induced. We stopped both drugs and started steroid therapy with prednisolone. Finally, about 9 months after restarting nivolumab, isolated adrenocorticotropic hormone (ACTH) deficiency was induced, and so we started replacement therapy with hydrocortisone. Taken together, we should bear in mind the possibility of a variety of irAEs when we use immune checkpoint inhibitors.
Subject(s)
Adrenocorticotropic Hormone/deficiency , Endocrine System Diseases/chemically induced , Genetic Diseases, Inborn/chemically induced , Hypoglycemia/chemically induced , Immune Checkpoint Inhibitors/adverse effects , Meningitis, Aseptic/chemically induced , Thyroiditis/chemically induced , Antineoplastic Agents, Immunological/administration & dosage , Antineoplastic Agents, Immunological/adverse effects , Antineoplastic Combined Chemotherapy Protocols , Atrophy/chemically induced , Endocrine System Diseases/diagnosis , Genetic Diseases, Inborn/diagnosis , Humans , Hypoglycemia/diagnosis , Immune Checkpoint Inhibitors/administration & dosage , Ipilimumab/administration & dosage , Ipilimumab/adverse effects , Japan , Male , Melanoma/drug therapy , Meningitis, Aseptic/diagnosis , Middle Aged , Nivolumab/administration & dosage , Nivolumab/adverse effects , Skin Neoplasms/drug therapy , Thyroid Gland/drug effects , Thyroid Gland/pathology , Thyroiditis/diagnosis , Thyroiditis/pathology , Melanoma, Cutaneous MalignantABSTRACT
Hypophysitis is rarely reported in patients receiving pembrolizumab-only immunotherapies. Since the clinical presentation is usually as isolated adrenocorticotrophic hormone (ACTH) deficiency, patients may be misjudged as having clinical symptoms due to cancer or chemotherapy. A 49-year-old male with laryngeal cancer applied to our clinic just after the tenth cycle of his pembrolizumab treatment, with weakness and nausea/vomiting. Serum morning cortisol and ACTH were 0.47 mcg/dl and 10.1 pg/ml, respectively; the remaining anterior pituitary hormone levels were normal. Pituitary MRI revealed mild glandular enlargement and loss of posterior pituitary bright-spot. All symptoms and signs improved with low-dose prednisolone. This is the second reported case of pembolizumab-associated isolated ACTH deficiency having abnormal pituitary MRI findings as we have reviewed all reported cases in the literature.
Lay abstract Immune check point inhibitors (ICIs) are used in order to enhance antitumoral immune mechanisms in certain cancers. As a result, immune-related side effects have commonly been reported in patients taking ICIs, one of which is hypophysitis. Pembrolizumab is a type of ICI which has rarely been associated with hypophysitis. Since the clinical presentation of pembrolizumab-associated hypophysitis is usually as isolated adrenocorticotrophic hormone deficiency and related cortisol insufficiency, patients may be misjudged as having clinical symptoms due to cancer or chemotherapy, due to shared symptoms such as fatigue, loss of appetite and nausea. Here we have reported a case with pembrolizumab-associated isolated adrenocorticotrophic hormone deficiency and reviewed all other cases available in the literature to improve our understanding of such patients.
Subject(s)
Adrenocorticotropic Hormone/deficiency , Antibodies, Monoclonal, Humanized/adverse effects , Hypophysitis/chemically induced , Immune Checkpoint Inhibitors/adverse effects , Laryngeal Neoplasms/drug therapy , Squamous Cell Carcinoma of Head and Neck/drug therapy , Humans , Male , Middle AgedABSTRACT
Up: A schematic-diagram of POU1F1-gene. Down right: an electrophoretogram of the detected novel pathogenic-variant in comparison with wild-type POU1F1 exon-6 sequence. Down left: Family pedigree of the two-siblings reported.
Subject(s)
Mutation , Phenotype , Transcription Factor Pit-1/genetics , Adrenocorticotropic Hormone/deficiency , Brain/abnormalities , Consanguinity , Endocrine System Diseases , Genetic Association Studies , Genetic Diseases, Inborn , Genetic Loci , Genetic Predisposition to Disease , Homozygote , Humans , Hypoglycemia , Magnetic Resonance Imaging , Pedigree , SiblingsABSTRACT
Immune checkpoint inhibitors (ICIs) are potent therapeutic options for many types of advanced cancer. The expansion of ICIs use however has led to an increase in immune-related adverse events (irAEs). Secondary adrenal insufficiency (AI) can be life-threatening especially in patients with delayed diagnosis. We retrospectively investigated secondary AI in ICI-treated patients. A total of 373 cancer patients treated with ICIs were included and evaluated. An adrenocorticotropic hormone (ACTH) deficiency was described in 13 patients. Among 24 patients with a combination of nivolumab and ipilimumab therapy, 7 patients (29%) developed secondary AI in a median time of 8 weeks during the combination therapy and 2 of 15 patients (13%) developed isolated ACTH deficiency during maintenance nivolumab monotherapy following the combination therapy. More than half of the patients (4/7) with a combination therapy-induced multiple anterior hormone deficiencies was diagnosed as secondary AI based on regular ACTH and cortisol tests with slight subjective symptoms. Secondary AI can arise frequently and rapidly in cancer patients receiving a combination ICI therapy, and thus we speculate active surveillance of AI using regular ACTH and cortisol tests during the combination therapy might be useful for avoiding life-threatening conditions due to secondary AI.
Subject(s)
Adrenal Insufficiency/diagnosis , Immune Checkpoint Inhibitors/adverse effects , Ipilimumab/adverse effects , Neoplasms/drug therapy , Nivolumab/adverse effects , Adrenal Insufficiency/blood , Adrenal Insufficiency/chemically induced , Adrenal Insufficiency/prevention & control , Adrenocorticotropic Hormone/blood , Adrenocorticotropic Hormone/deficiency , Adult , Aged , Aged, 80 and over , Antineoplastic Combined Chemotherapy Protocols , Biomarkers/blood , Delayed Diagnosis , Female , Humans , Hydrocortisone/blood , Hydrocortisone/deficiency , Immune Checkpoint Inhibitors/administration & dosage , Ipilimumab/administration & dosage , Male , Middle Aged , Monitoring, Physiologic , Neoplasms/blood , Neoplasms/immunology , Neoplasms/pathology , Nivolumab/administration & dosage , Retrospective StudiesABSTRACT
The patient was a 34-year-old woman. Surgical resection and chemotherapy had been performed on diagnosis of malignant melanoma in year X-9. Chronic thyroiditis was diagnosed in year X-8, but her thyroid function was normal. In November of the year X-1, the patient, who had metastasis to the left lung and the left main bronchus and radically unresectable metastases with distant metastases, was treated with the anti-PD-1 antibody nivolumab. In December X-1, we initiated levothyroxine sodium for hypothyroidism after the patient suffered indolent thyroiditis due to nivolumab. In March X, the nivolumab treatment was stopped because it proved to be ineffective, then in April, anorexia, fever, and general malaise were noted. Cortisol 5.0 and ACTH 17.5 were confirmed by blood test, and the patient was diagnosed with adrenal insufficiency and was admitted to the hospital. Head MRI showed no organic lesions, and a stress test showed abnormalities only in a CRH test (low response to both ACTH and cortisol). The patient was diagnosed with isolated ACTH deficiency due to nivolumab. Side effects of thyroid dysfunction due to nivolumab are frequently observed in Japan at a rate of 14.3%, and overseas at 5.9%. However, secondary adrenocortical dysfunction is observed in overseas clinical trials at a frequency of only about 0.3%. There are few reports of such complications, and we report this as a rare case.