D0287 - Severe Nausea and Hyperemesis Are Not Always Gastrointestinal: Non-GI Immune-Related Adverse Events Presenting as Upper GI Symptoms

Pooja J. Mude, DO¹, Jacqueline T. Chan, MD¹, John Erikson L. Yap, MD^2
1Augusta University Medical Center, Augusta, GA; ²Augusta University Medical College of Georiga, Augusta, GA

Introduction: Cancer therapy using immune checkpoint inhibitors (ICI) are increasingly utilized in the treatment of various types of advanced cancers, such as renal cell carcinoma (RCC), lung cancer and melanoma. While the mechanism of action in using the body’s innate immune system to fight cancer have been positive, there are documented cases of autoimmune side effects called immune-related adverse events (irAE). We present a patient on ICI that was thought initially to be having GI irAE but was, in fact, something else.

Case Description/Methods: A 61-year-old male with metastatic RCC status post right nephrectomy on Nivolumab and Ipilimumab was admitted due to 2-months of progressive generalized weakness and persistent nausea and vomiting. On presentation, vital signs demonstrated he was hypotensive at 88/66 mmHg and tachycardic at 102 bpm. Physical exam, laboratory parameters (CBC, CMP) and abdominal CT were unremarkable. The GI service was consulted to place a percutaneous endoscopic gastrostomy (PEG) for palliative feeding, but given the patient was on ICI therapy further evaluation was needed. A TSH (21.3mcIU/mL) was elevated and AM cortisol (< 0.5mcg/mL) was low. Hydrocortisone and levothyroxine therapy were immediately instituted. Thyroid and adrenal antibodies were negative and there was no serologic evidence of pituitary dysfunction consistent with an endocrine irAE. An esophagogastroduodenoscopy (EGD) was performed to evaluate for GI irAE, which was unremarkable. His symptoms resolved and he was able to eat with no issues. The patient ultimately did not need a PEG.

Discussion: Programmed cell death-1 (PD-1) and cytotoxic T-lymphocyte antigen 4 (CTLA-4) are proteins primarily involved in suppressing the immune reaction to self-antigens, resulting in immunologic tolerance. Unfortunately, neoplastic cells use the same protein activity to evade the body’s immune response. Nivolumab and Ipilimumab selectively inhibit (PD-1) and (CTLA-4), respectively, and lead to an increase in baseline T-cell specific immune response against tumor cells. This process can also result in autoimmune responses to various systems in the body, including gastrointestinal, endocrine, hepatic, pulmonary, dermatologic, and renal systems. With the increased utility of ICI in treating various malignancies, it is of the upmost importance to recognize different irAE to avoid delay in starting lifesaving treatments and to avoid unnecessary procedures like this particular case.


Disclosures:


Pooja J. Mude, DO¹, Jacqueline T. Chan, MD¹, John Erikson L. Yap, MD². D0287 - Severe Nausea and Hyperemesis Are Not Always Gastrointestinal: Non-GI Immune-Related Adverse Events Presenting as Upper GI Symptoms, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.