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Internal Medicine
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Poster
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Patient Care
Abstract Type
Case Report
Abstract
Disorders of the endocrine system are a potential complication of cancer treatment despite newer immunotherapy agents holding promise to improve patient outcomes. Breast cancer in particular requires pharmacologic intervention based on the receptor positivity. For example, a triple negative workup often requires neoadjuvant therapy with the newer immunotherapy agent pembrolizumab. Clinicians should be aware of the potential adverse effects of this drug, most notably adrenal insufficiency. This case follows a 52 year old hispanic female patient with a history of triple negative left sided breast cancer on immunotherapy with pembrolizumab, who presented to the emergency department after a syncopal episode in office associated with altered mental status. She was admitted to the intensive care unit (ICU) for persistent hypotension despite intravenous fluid administration, and was started on a norepinephrine infusion. Her nadir systolic blood pressure on admission to the ICU was 54 mmHg, with a mean arterial blood pressure (MAP) of 46 mmHg. Laboratory testing revealed a low sodium (135 mmol/L); low potassium (2.7 mmol/L); a low morning cortisol of 2 mcg/dL; and thyroid studies consistent with a hypothyroid state: low free T3 ( <0.2 pg/mL), low free T4 (0.12 ng/dL), and a high TSH (58.16 uIU/mL). These results prompted a treatment regimen that consisted of both levothyroxine and hydrocortisone. Furthermore, during the course of her hospitalization, the patient also required treatment with both fludrocortisone and midodrine for continued blood pressure control. The purpose of this case report is to raise awareness over the potential endocrine-related complications of pembrolizumab, including hypothyroidism with concomitant adrenal insufficiency. Recognition of adrenal insufficiency in this setting is important, as correction of hypothyroidism without steroid therapy can increase glucocorticoid metabolism and worsen adrenal insufficiency.
Also presented as an Oral Presentation.
Recommended Citation
Lopez, Miguel A.; Trujillo Acosta, Mario; Villarreal Calderon, Jose Romero; and Garcia, Laura, "An Endocrine Enigma: The Implications of Pembrolizumab Therapy" (2025). Research Symposium. 106.
https://scholarworks.utrgv.edu/somrs/2025/posters/106
Included in
Endocrinology, Diabetes, and Metabolism Commons, Internal Medicine Commons, Medical Immunology Commons, Medical Pharmacology Commons, Oncology Commons
An Endocrine Enigma: The Implications of Pembrolizumab Therapy
Disorders of the endocrine system are a potential complication of cancer treatment despite newer immunotherapy agents holding promise to improve patient outcomes. Breast cancer in particular requires pharmacologic intervention based on the receptor positivity. For example, a triple negative workup often requires neoadjuvant therapy with the newer immunotherapy agent pembrolizumab. Clinicians should be aware of the potential adverse effects of this drug, most notably adrenal insufficiency. This case follows a 52 year old hispanic female patient with a history of triple negative left sided breast cancer on immunotherapy with pembrolizumab, who presented to the emergency department after a syncopal episode in office associated with altered mental status. She was admitted to the intensive care unit (ICU) for persistent hypotension despite intravenous fluid administration, and was started on a norepinephrine infusion. Her nadir systolic blood pressure on admission to the ICU was 54 mmHg, with a mean arterial blood pressure (MAP) of 46 mmHg. Laboratory testing revealed a low sodium (135 mmol/L); low potassium (2.7 mmol/L); a low morning cortisol of 2 mcg/dL; and thyroid studies consistent with a hypothyroid state: low free T3 ( <0.2 pg/mL), low free T4 (0.12 ng/dL), and a high TSH (58.16 uIU/mL). These results prompted a treatment regimen that consisted of both levothyroxine and hydrocortisone. Furthermore, during the course of her hospitalization, the patient also required treatment with both fludrocortisone and midodrine for continued blood pressure control. The purpose of this case report is to raise awareness over the potential endocrine-related complications of pembrolizumab, including hypothyroidism with concomitant adrenal insufficiency. Recognition of adrenal insufficiency in this setting is important, as correction of hypothyroidism without steroid therapy can increase glucocorticoid metabolism and worsen adrenal insufficiency.
Also presented as an Oral Presentation.
