- 期刊
- OpenAccess
- Ahead-of-Print
Fulminant Diabetes Associated with Immunotherapy Related Adverse Event: A Case Report
摘要
Immune checkpoint inhibitors (ICI) are potent and promising immunotherapeutic agents that are increasingly used for the management of various types of advanced cancers. ICI-induced immune system activation however may lead to autoimmune inflammation. Typical side effects of ICIs include immune-related adverse events (irAEs) affecting numerous endocrine glands. Recently, diabetes mellitus has been recognized as a potential side effect of these medications. A 62-year-old non-obese, Taiwanese male without familial or prior history of diabetes, was diagnosed with renal cell carcinoma (stage Ⅲ), and underwent a right nephrectomy followed by immunotherapy treatment with pembrolizumab at Taipei Veterans General Hospital (TVGH). Six months later, he experienced excessive thirst, urinary frequency, and significant weight loss. Extreme hyperglycemia (790 mg/dL), metabolic acidosis (venous pH 7.283, HCO3- 16.1 mmol/L), ketonuria, and hyperkalemia (5.6 mEq/L) were documented, compatible with diabetes and metabolic acidosis. His presenting HbA1c was 7.2 % and his fasting serum C-peptide was 0.32 ng/mL. Intravenous fluid and insulin infusion (IVII) were immediately initiated and transitioned to multiple daily insulin injections (MDII) during his hospital stay at Taipei Medical University Hospital. Pembrolizumab was withdrawn, but the patient became insulin-dependent with a follow-up C-peptide of less than 0.01ng/ mL two months after hospital discharge. With brittle glycemic control and frequent hypoglycemia at home, he consulted Cheng Hsin General Hospital for fine-tuning of insulin therapy. His diabetes was eventually stabilized with insulin requirement of 0.49 u/kg/d and HbA1c at 6.4 - 6.8 %. In the absence of autoantibodies, his diabetes was categorized as other specific type of diabetes. In short, ICI therapy may result in endocrine adverse events, highlighting the importance of early recognition and prompt treatment to optimally manage this emerging disorder.