As a result, his presentation to our hospital was delayed, which necessarily delayed the diagnosis and treatment. the patient’s adrenocorticotropic hormone (ACTH; 4.5 pg/ml) and cortisol (0.1 g/dl) levels were lower than normal, while those of additional pituitary hormones were higher than SRPKIN-1 normal. This case was consequently diagnosed as isolated ACTH deficiency induced by nivolumab. Magnetic resonance imaging (MRI) showed normal pituitary glands. Hydrocortisone alternative therapy improved the medical symptoms early and enabled the patient to restart nivolumab therapy. Isolated ACTH deficiency due to nivolumab, a PD-1 immune checkpoint inhibitor antibody, is definitely a rare event. This report may be useful for avoiding delays in the analysis and treatment of this life-threatening irAE actually if no pituitary abnormalities are recognized via MRI. (27) performed an autopsy analysis of the pituitary glands of individuals with malignancy treated by CTLA-4 blockade and reported that higher manifestation of CTLA-4 in the pituitary gland was related to more severe hypophysitis based on a type II or type IV allergy to anti-CTLA-4 antibodies. To the best of our knowledge, there have been no reports within the pathogenesis IKK-gamma antibody of nivolumab-induced hypophysitis. We are urologists and luckily possess encounter in the treatment of adrenal insufficiency. Thus, we were able to diagnose the patient and start treatment based on the patient’s symptoms and general laboratory data without waiting for the results of the endocrine exam. These case reports, including our own, may become useful for avoiding delays in the analysis and treatment of this life-threatening irAE, actually without findings of pituitary abnormalities on MRI. Hypophysitis is well known to cause isolated ACTH deficiency by an autoimmune-related mechanism (28). While a rapid ACTH test should have been carried out for any definitive analysis (29), the period from the onset of symptoms to the analysis was extremely very long; therefore, diagnostic treatment was prioritized. The endocrine system tests exposed that among the anterior pituitary hormones, only the levels of ACTH were lower than normal, with the levels of additional anterior pituitary hormones, such as PRL, LH, SRPKIN-1 FS and TSH, being higher than normal; furthermore, the cortisol levels were also lower than normal. Thus, this case was diagnosed as isolated ACTH deficiency induced by nivolumab, and hydrocortisone (Cortril?) was continually administered according to the Japan Endocrine Society clinical practice recommendations (29). The temporarily high TSH value was considered to be due to the combination of the following three factors: The possible insufficiency of the thyroid medicines for main hypothyroidism, decreased conversion to free triiodothyronine like a biological reaction due to the deterioration of general condition, and adrenocortical hypofunction. When we experienced this patient, nivolumab was recommended as the treatment after antiangiogenic therapy based on the results of the CheckMate 025 study (8). Given that our patient had been going through various adverse events associated with molecular-targeted medicines, he regarded as the medical symptoms that occurred at the time to become much like previously experienced symptoms. Consequently, his demonstration to our hospital was delayed, which necessarily delayed the analysis and treatment. This case shows the importance of patient education. Since our encounter in treating this patient, we have strengthened our approach to patient education concerning adverse events when introducing nivolumab. The Western Association of Urology recommendations have been updated based on the results of the phase III Checkmate-214 medical trial (30,31). That trial showed the combination of nivolumab and ipilimumab in treatment-na?ve individuals with clear-cell metastatic renal cell carcinoma of intermediate and poor risk (classified from the International Metastatic Renal Cell Carcinoma Database Consortium) leads to first-class survival in comparison to sunitinib. This treatment regimen will soon be SRPKIN-1 authorized in Japan, that may necessitate further extreme caution. Defense check-point inhibitors are relatively fresh restorative providers, so our encounter with their connected irAEs remains insufficient. Because physicians possess few opportunities to experience instances different irAEs separately, the analysis and treatment of these events can be facilitated from the publication of detailed medical case reports. We reported a case of adrenal insufficiency that was probably induced by nivolumab after pseudo-progression. With this case-in contrast to most autoimmune hypophysitis instances that can SRPKIN-1 typically become diagnosed by MRI-the pituitary gland showed no enlargement. The careful observation of a patient’s medical symptoms without resorting to imaging examinations enables the effective treatment at an earlier point.
