We had an interesting case a few weeks ago with a patient on adjuvant nivolumab. He presented with marked fatigue, nausea, weight loss, hyponatremia and orthostatic hypotension. Therapy was held and we did endocrine labs and a brain MRI looking for hypophysitis which he did not have. We treated him supportively with IVF and frequent visits. It was not until he presented to the ER with chest pain radiating to his back that reflux/gastritis was considered. Endoscopy confirmed esophagitis/gastritis and he is much better on omeprazole and steroids. Have others seen this type of presentation?
Wow! Thanks for sharing this case Virginia. I too would have suspected hypophysitis with the initial symptoms described. How frightening for this gentleman who probably though he was having a heart attack (myocarditis from the provider perspective)! Was there anything, in hindsight, that may have been an earlier clue to the diagnosis? Or was it due diligence in the ER that ultimately led to diagnosis?
A great example of how ICIs continue to challenge even the most experienced providers!!