, 17 tweets, 22 min read Read on Twitter
It's time for #TwitterReport! Get out your illness scripts and problem representations.

Case: A 65yoM with metastatic melanoma goes to the ER with RLE edema: doppler shows a femoral DVT. He also says he's been getting more tired over the last 4wk.

What else do you want to know?
PMH: HTN, HL, T2DM (now diet controlled), metastatic melanoma
PSH: none
Meds: HCTZ, metoprolol, atorvastatin, pembrolizumab/ipilimumab (last cycle 2 weeks ago)
Social: lives with wife and dog at home. From a local rural area. Never smoker/alcohol. Former construction worker.
ER Triage Vitals:
-Temp 37*C
-HR 60
-BP 90/54
-RR 12
-SpO2 98% on room air

What else do you want to know?
1/x #TwitterReport

Patient is sleeping 12-14h per day. Still tired. He doesn’t snore. Has no OSA.

No chest pain, sob, doe, orthopnea, cough. No abdominal pain. No diarrhea. No n/v.

Has a rash that started after starting Pembro/ipi. Acneform. Better with topicals.
2/x #TwitterReport

No temperature sensitivity. Maybe decreased libido, but he thinks he’s just tired.

Exam: BP on sitting up = 70/45 (orthostatic)
HEENT: normal
Neuro: Aaox4, normal CN’s. Normal strength. Normal sensation.
Cards, Pulm, abd: normal
3/x #TwitterReport

Exam cont:
Skin: resection scar from melanoma on upper back. Well healed. Otherwise normal.
Thyroid: no modules or enlargement

WBC: 7
Hb: 13 (at baseline)
Plt: 200

BMP normal including Na, K, Cr (baseline 1.0), glucose

TSH (prior) 0.2 / FT4 (prior) 2.1
4/x #TwitterReport

New TSH 0.001, New FT4 1.9

EKG normal sinus
CXR normal
POCUS: no pericardial effusion, normal EF within error of the test

UA normal.

I have requests for CTA-PE, AM cortisol.

What else are you worried about? What else do you want??

You guys are on point. Calcium 9. Albumin 3.

AM cortisol is 2. ACTH is low.

CTH shows no bleeding. Brain mass is nearly gone.

MRI shows hypophysitis.

Diagnosis: immune checkpoint inhibitor induced hypophysitis manifesting as adrenal insufficiency, hypothyroidism
6/x #TwitterReport

Regarding the FT4 being normal (not low!) despite hypophysitis —

The thought was he did have an irAE previously: subclinical hyperthyroidism. With the hypophysitis, his TSH has become zero and the inflammation from pembro-ipi is still driving some FT4
7/x #TwitterReport

Everyone’s reasoning was spot on. A few points are worth emphasizing:

1) common things are still common, even in patients on immune checkpoint inhibitors.

A cancer patient with a new DVT, Fatigue, and “no get up and go” (?DOE)? certainly deserves a CTA-PE.
8/x #TwitterReport

2) New things are sometimes common too!

I retweeted all of the citations that folks left for us (Thanks!!! This is why I love Twitter!) showing that the rates of immune related adverse events with ICI is actually decently high. Hypophysitis is 5-10%!
9/x #TwitterReport

Checkpoint inhibitor immune related adverse events, when they involve non-endocrine organs, are often diagnoses of exclusion. But they can sometimes advance quite rapidly, so you have to be savvy and your work up to avoid a delay in steroids.
10/x #TwitterReport

Bottom line: for patients on Immune checkpoint inhibitors, always ask yourself “could it be the drug? And if not, then what?“

Thanks for playing everyone! As always, we want your feedback so we can make these the better learning experience.
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