Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki-city, Okayama, Japan.
Medicine (Baltimore). 2024 Mar 8;103(10):e37204. doi: 10.1097/MD.0000000000037204.
The use of immune checkpoint inhibitors (ICIs) is gradually increasing; ICIs produce a variety of immune-related adverse events (irAEs), especially ICI-induced hypoadrenocorticism, which can be a lethal complication if treatment is delayed.
A 63-year-old man received chemotherapy with pembrolizumab for nonsmall cell lung cancer. He developed drug-induced interstitial pneumonia 366 days after receiving pembrolizumab and was treated with prednisolone. Five hundred thirty-seven days later, he developed drug-induced eosinophilic enteritis, and pembrolizumab was discontinued and prednisolone was continued. After discontinuation of prednisolone, general malaise and edema of the lower extremities appeared, and adrenal insufficiency was suspected.
In blood tests on admission adrenocorticotropic hormone (ACTH) was 2.2 pg/mL and cortisol was 15 μg/dL, with no apparent cortisol deficiency. However, the cortisol circadian rhythm disappeared and remained low throughout the day; a corticotropin-releasing hormone stimulation test showed decreased reactive secretion of ACTH. Pituitary magnetic resonance imaging showed pituitary emptying, suggesting Empty Sella syndrome.
We started hydrocortisone and his symptoms were improved.
The administration of high-dose steroids after ICI administration may mask the symptoms of hypoadrenocorticism as irAEs. Therefore, we should bear in mind the possibility of hypoadrenocorticism when we stop steroid therapy in patients who are treated with steroids after ICI administration.
免疫检查点抑制剂（ICIs）的应用逐渐增多；ICIs 会产生多种免疫相关不良反应（irAEs），尤其是 ICI 诱导的肾上腺皮质功能减退症，如果治疗延误，可能会导致致命的并发症。
一名 63 岁男性因非小细胞肺癌接受了 pembrolizumab 化疗。他在接受 pembrolizumab 后 366 天出现药物性间质性肺炎，并接受了泼尼松龙治疗。537 天后，他出现药物性嗜酸性粒细胞性肠炎，并停用了 pembrolizumab，继续使用泼尼松龙。停用泼尼松龙后，出现全身不适和下肢水肿，疑似肾上腺皮质功能减退症。
入院时的血液检查显示促肾上腺皮质激素（ACTH）为 2.2pg/mL，皮质醇为 15μg/dL，皮质醇缺乏不明显。然而，皮质醇昼夜节律消失，全天维持低值；促皮质素释放激素刺激试验显示 ACTH 反应性分泌减少。垂体磁共振成像显示垂体排空，提示空蝶鞍综合征。
我们开始使用氢化可的松，他的症状得到改善。
ICI 给药后给予大剂量类固醇可能会掩盖作为 irAEs 的肾上腺皮质功能减退症的症状。因此，对于接受 ICI 治疗后接受类固醇治疗的患者，我们应在停止类固醇治疗时牢记肾上腺皮质功能减退症的可能性。
