Immune checkpoint inhibitor-induced thyroid storm and fatal cardiogenic shock in a patient with metastatic melanoma

Abstract :

Background: Immune checkpoint inhibitors significantly improve mortality in advanced melanoma. However, these agents, particularly as combination therapy, have significant adverse effects that often manifest as autoimmune presentations. In this case, we describe immune checkpoint inhibitor-induced thyroid storm and fatal cardiogenic shock in a patient with metastatic melanoma.Case: 65-year-old gentleman with metastatic melanoma presented with syncope. He was started on nivolumab and ipilimumab 11 days prior to admission, with pre-initiation thyroid tests in normal range. Workup revealed new thyrotoxicosis, complete heart block, rhabdomyolysis, troponin 2.76, and LVEF 60% on echocardiogram. Management was initiated with methimazole. Additionally, a dual chamber pacemaker was placed because although complete heart block is a known complication of hyperthyroidism, reversal of thyrotoxicosis does not guarantee heart block resolution. A subsequent asystolic episode was attributed to lead capture failure, and repeat studies showed thyroid storm, troponin >50, and LVEF 20%. The patient deteriorated into cardiogenic shock requiring emergent IABP. Ultimately, family opted for comfort measures.Conclusions: This is the first reported case of immune checkpoint inhibitor-induced thyrotoxicosis complicated by complete heart block, with subsequent thyroid storm leading to terminal cardiogenic shock in a patient with metastatic melanoma.

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