Hypoadrenalism secondary to hypophysitis causing cerebral oedema: a rare complication of dual checkpoint inhibitor therapy

<h3>Background</h3> The advent of immune checkpoint inhibitor therapy(iCP) has revolutionised treatment for malignant melanoma and other malignancies. Hypophysitis with resulting central hypoadrenalism is a recognised complication of iCP treatment.¹ Diffuse cerebral oedema is a rarely reported complication in adrenal crisis.² <h3>Case</h3> A 47-year-old lady who received 4-months of ipilimumab and nivolumab for malignant melanoma with BRAF positive gene mutation presented with headache and confusion following COVID-19 vaccination. Examination demonstrated hypotension, nuchal rigidity and mild papilloedema. Computerised tomography of brain revealed effacement of the sulci and gyri with basal cistern compression. Magnetic Resonance Imaging of brain which was done four weeks prior to the presentation showed an anterior pituitary lesion with differential of macroadenoma or metastatic deposit. Serum cortisol level was 13 nmol/L(183–624) and sodium 130mmol/L. Following hydrocortisone administration, recovery was excellent. <h3>Discussion</h3> Hypophysitis is a common iCP related adverse event, but clinical presentation of adrenal crisis with diffuse cerebral oedema is rarely reported. We concluded the recent COVID-19 vaccination may have triggered her presentation. This treatable complication is important to recognise with expanding usage of iCP, as it carries excellent prognosis if promptly identified and managed. <h3>References</h3> Spain, <i>et al.</i> How we treat neurological toxicity from immune checkpoint inhibitors. <i>ESMO Open.</i> 2019;<b>4</b>:e000540. Park, <i>et al.</i> Recurrence of hypophysitis after immune checkpoint inhibitor rechallenge. <i>Oncologist</i>, 2022;<b>27</b>(12):e967–e969.