ODP264 An Unusual Etiology of Hypothyroidism and New-Onset Insulin-Dependent Diabetes: A Rare Side Effect of Opdivo

Introduction

Nivolumab, a monoclonal antibody targeting programmed cell death 1 receptor, is prescribed for many advanced cancers like malignant melanoma, non-small cell lung cancer, renal cell carcinoma (RCC), etc. with increased use of this medication, the incidence of immune-related side effects is also on the rise. A combined medication side effect of new-onset diabetes and hypothyroidism associated with Nivolumab use is rare. We present a case of Nivolumab-induced hypothyroidism with new-onset insulin-dependent diabetes.

Case presentation

A 59-year-male with a past medical history of right RCC status post nephrectomy, non-ischemic cardiomyopathy with an ejection fraction of 25-30% on goal-directed therapy/implantable cardioverter-defibrillator, hypertension, hyperlipidemia, and chronic kidney disease stage 3 who presented to the emergency department with complaints of chest pain at rest. The pain was 5/10 in severity and non-radiating. It was relieved by sublingual nitroglycerine en route to the hospital. It was associated with fatigue, nausea, polyuria, and polyphagia. He denied any history of pre-diabetes/diabetes or thyroid disease. Of note, about six months prior to this admission, he was placed on nivolumab for his RCC. Vitals were BP 121/83, RR 20, HR 85, T 97.8°F, and 97% oxygen saturation on room air. The cardiopulmonary exam was unremarkable. An electrocardiogram showed sinus rhythm with normal rate and no ST/T wave changes. Troponin level was 0. 01 ng/mL (normal:: <0. 04 ng/mL) Chest x-ray revealed no acute pathology. Labs showed glucose of 1090 mg/dL (normal:: 70-100 mg/dL) and thyroid-stimulating hormone (TSH) of >50,000 IU/L (normal:: 0.3-4.2 IU/L). Urinalysis was positive for ketones; 20 mg/dL (normal:: negative). Venous blood revealed a pH level of 7.344. An acute coronary syndrome was ruled out, and he was admitted for management of hyperosmolar hyperglycemic state (HHS) and hypothyroidism. Due to a low level of C-peptide: <0.5 ng/mL (normal:: 1.1-4.4 ng/mL) and high TSH, a new-onset insulin-dependent autoimmune diabetes and hypothyroidism induced as a side effect of nivolumab was suspected. Nivolumab was discontinued from his medication regimen. Endocrinology was consulted for the management of HHS and hypothyroidism. Insulin drip and levothyroxine were started, and he was transferred to the intensive care unit for close monitoring. Thereafter, his metabolic derangements improved with the resolution of hyperglycemia and electrolyte disturbances. On discharge, his symptoms improved and he was advised to stop taking nivolumab.

Discussion

Nivolumab has been reported in the literature to cause worsening of glycemic control and is also rarely reported as a cause of insulin-dependent diabetes due to autoimmune effects. Its effects on the thyroid are usually reported as transient thyrotoxic period which either resolves to euthyroid or rarely hypothyroidism which is what happened with our patient. Recognizing the side effects of Nivolumab and periodic monitoring can help earlier diagnosis and management with better outcomes.

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An Unusual Etiology of Hypothyroidism and New-Onset Insulin-Dependent Diabetes: A Rare Side Effect of Nivolumab

Nivolumab, a monoclonal antibody targeting programmed cell death 1 receptor, is prescribed for many advanced cancers like malignant melanoma, non-small cell lung cancer, renal cell cancer, etc. With the increase in the use of nivolumab like immunotherapy, the incidences of immune-related side effects are also on the rise. Immune-related endocrinopathies like hypothyroidism and new-onset type 2 diabetes mellitus associated with nivolumab use, although rare, are already documented in the literature. Here we present a case of hypothyroidism and new-onset type 2 diabetes mellitus in a renal cell cancer patient receiving nivolumab for the past six months. The patient was managed successfully with discontinuation of nivolumab, intravenous insulin, and thyroid hormone replacement therapy. These types of endocrinopathies can be fatal; hence, prompt diagnosis and management are required. Thus, not only physicians' awareness of such endocrinopathies among nivolumab-treated patients but also patients' awareness regarding warning signs and symptoms are essential.

Dysphagia Lusoria: A Little Known Cause of Chest Pain

Dysphagia lusoria is a congenital abnormality characterized by an aberrant right subclavian artery. It often presents as either an incidental finding on imaging or chronic dysphagia. We describe the case of a 66-year-old female who presented with severe chest pain, worse with swallowing, along with an ongoing globus sensation. She was found to have a negative cardiac workup for ischemia with a subsequent computed tomography angiogram (CTA) of the chest showing an abnormal right subclavian artery. We emphasize the unique diagnostic approach of this rare anatomical anomaly and its potential presentation that worsens with deglutition.

Repaglinide-Induced Acute Pancreatitis

Acute pancreatitis is a common reason for hospitalization in the United States and can have a high degree of morbidity and mortality if not treated appropriately. Establishing the diagnosis and following guideline-directed medical therapy are both important. In the Western world, the most common causes include acute alcohol overuse, hypertriglyceridemia, gallstone pancreatitis, post-instrumentation including endoscopic cholangiopancreatography, and medication side effects. Our team describes the case of an 84-year-old male that was found to have acute pancreatitis secondary to repaglinide, a commonly used medication for the management of diabetes mellitus. The diagnosis was made based on the imaging findings, physical examination, and the corresponding laboratory markers. The patient was also found to have a blood-alcohol level at baseline and triglyceride levels within normal range. The patient’s symptoms resolved with the cessation of repaglinide administration. Our team hopes to make the medical community more aware of the potential association between repaglinide and the potentially rapidly debilitating disease. 

Vaginal birth after caesarean section (VBAC) in women with spontaneous labour: predictors of success

We evaluated the predictors of VBAC success in Jordanian women with a single previous low transverse caesarean section of a gestational age of at least 28 weeks, followed by a trial of spontaneous labour at two tertiary hospitals between January 2008 and February 2010. Among 207 women, 117 (57%) women achieved a successful VBAC. Multivariate analysis showed that a cervical dilatation of ≥ 7 cm at the time of previous caesarean section was an independent predictor of successful VBAC (with a success rate of 80%). Parity of ≥ 2 was significantly associated with increased odds of success (OR = 2.7, 95% CI: 1.2, 6.2). Compared with women who had no previous VBAC, those with previous VBAC had higher odds of success (OR = 3.8 (95% CI: 1.5, 9.5). We concluded that women with a previous caesarean section who achieved a cervical dilatation of ≥ 7 cm before caesarean, had a previous history of successful VBAC and had parity of ≥ 2, have the greatest likelihood of successful VBAC.

Indications and outcome for obstetric patients' admission to intensive care unit: a 7-year review

The objective of this retrospective study was to investigate the indications, interventions and clinical outcome of pregnant and newly delivered women admitted to the multidisciplinary intensive care unit at the King Abdullah University Hospital in Jordan over a 7-year period from January 2002 to December 2008. The collected data included demographic characteristics of the patients, mode of delivery, pre-existing medical conditions, reason for admission, specific intervention, length of stay and maternal outcome. A total of 43 women required admission to the intensive care unit (ICU), which represented 0.37% of all deliveries. The majority (95.3%) of patients were admitted to the ICU postpartum. The most common reasons for admissions were (pre)eclampsia (48.8%) and obstetric haemorrhage (37.2). The remainder included adult respiratory distress syndrome (6.9%), pulmonary embolism (2.3%) and neurological disorders (4.6%). Mechanical ventilation was required to support 18.6% of patients and transfusion of red blood cells was needed for 48.8% of patients. There were three maternal deaths (6.9%). A multidisciplinary team approach is essential to improve the management of hypertensive disorders and postpartum haemorrhage to achieve significant improvements in maternal outcome. A large, prospective study to know which women are at high risk of admission to the intensive care units and to prevent serious maternal morbidity and mortality is warranted.

Meconium-stained amniotic fluid in term pregnancies-a clinical view

The objective of this study was to explore details of the clinical relationship between meconium-stained amniotic fluid (MSAF) in labour, abnormal fetal heart pattern and meconium aspiration (MA). This was a prospective study carried out in Princess Badeea Teaching hospital during a 6-month period from March to September 1997. During the study period 344 (8.5%) of the deliveries had MSAF (344 women). Continuous fetal heart monitoring was routinely used and 36 women with MSAF (10.5%) needed to be delivered by caesarean section because of fetal distress (diagnosed by abnormal fetal heart pattern) in early labour, compared with 0.95% in those with clear amniotic fluid (CAF), (P <0.00001). Many infants in the MSAF group had a low Apgar score and required ventilation at birth. Nineteen infants (5.5%) developed MA, three of whom (15.8%) died. We conclude that there is an association between MSAF, abnormal fetal heart pattern in labour and a low Apgar score and that it should be considered a high risk situation. MA a problem that occurs with particulate meconium was significantly related to abnormal fetal heart pattern and longer length of labour.

Has consanguinity any impact on occurrence of pre-eclampsia and eclampsia?

In this study we tested the hypothesis of an association between consanguinity and pre-eclampsia/eclampsia. This is a case-control study conducted at Princess Badea Teaching Hospital, Irbid-Jordan during the period May 1997-April 1998. The study population were Jordanian women delivered at Princess Badea Teaching Hospital with or without hypertensive disorders of pregnancy. The total number was 208 pre-eclamptic/eclamptic women (76 primiparous and 132 multiparous) and 618 randomly selected non-hypertensive women. In primiparous as well as multiparous women, it was evident that neither consanguinity nor the degree of the relationship to the husband in consanguineous marriages had an impact on the incidence of preeclampsia/eclampsia. However, comparing the incidence of consanguinity between pre-eclamptic/eclamptic and non-hypertensive, multiparous women married to a relative other than first cousin, the P value was 0.0248, which we explained as chance incidence. When we compared the incidence of consanguineous marriages as a whole between pre-eclamptic/eclamptic and non-hypertensive, multiparous women, there was no evidence of any impact of consanguinity on the incidence of pre-eclampsia/eclampsia.

Predictive value of human chorionic gonadotrophin beta-hCG in early pregnancy after assisted conception

OBJECTIVE

This study was designed to evaluate the predictive value of beta-hCG levels in predicting the pregnancy outcome.

METHODS

A retrospective analysis was done on 423 pregnant patients following assisted conception (stimulated in vitro fertilization [SIVF] and stimulated intra uterine insemination [SIUI]). These were monitored with plasma beta-hCG on day +18 post hCG injection. Ongoing pregnancy was defined as greater than 20 weeks.

RESULTS

Four hundred twenty three patients had a positive serum quantitative beta-hCG level 18 days post hCG injection. Of these 321 (75.9%) were ongoing pregnancies. The spontaneous miscarriages were 98 (23.2%), and four ectopic pregnancies were recorded. Of the successful pregnancies, 279 were single births, and 42 were multiple births (15.1%), that is either twins (31) or triplets (11). Tables were calculated to help predicting the pregnancy outcome.

CONCLUSIONS

It can be shown that +18 levels of beta-hCG in cases of assisted conception are useful and provide predictive information concerning pregnancy outcome which should be helpful for the staff and the infertility patients.