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Anaphylaxis — ABIM Board MCQ

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HardRheumatology/Allergy/ImmunologyAnaphylaxisABIM Board

A woman receiving nivolumab develops fatigue, nausea, sodium 127 mEq/L, morning cortisol 1.2 microg/dL, low ACTH, low free T4, and an inappropriately normal TSH. She is stable without mass-effect symptoms. Which replacement sequence is safest?

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Correct answer: E — Start glucocorticoid replacement before introducing thyroid hormone therapy

The best answer is “Start glucocorticoid replacement before introducing thyroid hormone therapy”. Checkpoint-inhibitor hypophysitis has caused central adrenal insufficiency and central hypothyroidism. Cortisol replacement must precede levothyroxine because increasing metabolic demand and cortisol clearance can precipitate adrenal crisis. Mineralocorticoid replacement is generally unnecessary in secondary adrenal failure because aldosterone is largely preserved. A normal or mildly abnormal MRI does not exclude hypophysitis, and the low free T4 does not represent thyrotoxicosis.

Reference: ASCO Guideline: Immune-related adverse events: https://pmc.ncbi.nlm.nih.gov/articles/PMC6481621/