Preethi Polavarapu MD, Padmaja Akkireddy MD

Division of Diabetes, Endocrinology and Metabolism, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198

• Our case illustrates that patients with

preexisting Graves’ disease can develop

thyroiditis after receiving immune checkpoint

inhibitors, and hence, frequent monitoring with

thyroid function tests are needed

• Thyroid dysfunction is one of the

common immune-related adverse events

associated with immune checkpoint

inhibitors like Nivolumab

• Thyroiditis or primary hypothyroidism is

the most commonly reported

presentation. Graves’ disease is less

frequently reported

• We report a case of preexisting Graves’

disease patient on antithyroid meds who

developed thyrotoxicosis followed by

hypothyroidism after receiving Nivolumab

therapy.

CASE PRESENTATION

• 66 y/o female patient with newly

diagnosed metastatic melanoma

presented to us for evaluation of

abnormal thyroid test after her second

cycle of Nivolumab

• She has a long-standing history of

Graves’ disease and has been on

methimazole since her diagnosis

• She presented with weight loss,

palpitations, and tremors four weeks after

the start of Nivolumab

CONCLUSION

INTRODUCTION

Thyrotoxicosis from Nivolumab in a Patient with Preexisiting Graves’ Disease

• On exam, she was tachycardic with tremors

noted to outstretched hands and had diffusely

enlarged thyroid

DISCUSSION

• Endocrinopathies are the most common

immune-related adverse events

associated with the use of these agents,

with thyroid dysfunction being more

common

• Timeline for developing the thyrotoxic

phase is usually five weeks but can also

occur earlier, which is followed by the rapid

development of either euthyroid or

hypothyroid phase

• Management during the thyrotoxic phase

is usually beta-blockers

• Current guidelines recommend checking

thyroid function test before initiation of

therapy and every two weeks after the

diagnosis of thyrotoxicosis until they

become euthyroid or hypothyroid

• In patients who are euthyroid on treatment

guidelines recommend to follow thyroid

function test before every cycle

TEST 10/18 12/18 1/19 2/19 3/19

TSH

(0.4-4.5uIU/ml)

0.02 89.71 >100 16.973 4.63

Free T4

(0.8-1.6 ng/dl)

3.85 0.16 1.09

TSI

(<122%)

165

0

20

40

60

80

100

120

10/18/18 11/18/18 12/18/18 1/18/19 2/18/19

TSH

ng/

dl

DATE

Methimazole10mg daily

Methimazole Stopped

Levothyroxine 75mcg daily

Levothyroxine88mcg daily

Table 1: Thyroid Function Test

Figure 1: Treatment Course

Contact Info: Preethi Polavarapu ( preethi.polavarapu@unmc.edu ) Padmaja Akkireddy (padmaja.akkireddy@unmc.edu)