Multiple nonspecific symptoms in a patient treated by pembrolizumab

Victoria Van Hove, Sebahat Ocak, Etienne Delgrange Published in the journal : May 2021 Category : Internal Medicine

Summary :

Immune checkpoint inhibitors, such as the receptor programmed cell death protein 1 (PD-1) or PD-1 ligand 1 (PD-L1), which are new therapeutic weapons against cancer, which are increasingly used nowadays.

This case report concerns a 72-year-old man treated by pembrolizumab (Keytruda®), a PD-1 inhibitor, in first-line systemic treatment of an Stage IVA lung adenocarcinoma. Three weeks before his eighth cure, the patient’s general condition deteriorated, including loss of appetite, fatigue, nausea, and a slight weigh loss. He also reported headaches. As an adrenal insufficiency was suspected, a substitution treatment consisting of hydrocortisone was initiated. The originality of this case lies in the relevance of also considering non-specific symptoms in cancer patients under immunotherapy, the emergency of the diagnosis, and the recommended medical management.

The aim of this article is direct your attention to this rare but potentially fatal adverse event of immunotherapy, with its new treatments that you will encounter increasingly often in your practice, and to revise some cases already published in the literature , in addition to another personal case.

What is already known about the topic?

Immunotherapies are increasingly employed in oncology. Concerning their toxicities, those related to the endocrine system are at times difficult to recognize and may be fatal in the absence of diagnosis. Their physiopathology is still poorly understood.

What does this article bring up for us?

This article informs us about the different presentation modes of endocrine disorders induced by immu-notherapy, in addition to their incidence, evolution, and main symptoms that should catch our attention in patients under such medications. It points out the differences between the different immunotherapy agents. It provides guidelines that should be followed in case of a potential hypophysitis, as well as an opportunity to discuss the possibility of systematic screening.

Key Words

Adrenal insufficiency, hypophysitis, immunotherapy, pembrolizumab