One month after initiation of the immunotherapy (IT) the patient experienced a irHypophysitis (CTCAE 3) that was substituted with hydrocortisone as well as an irThyroiditis that was substituted with levothyroxine. Three months after initiation of the IT the patient also developed a colitis (CTCAE 2) that was confirmed by an endoscopical biopsy. A few weeks later he also showed arthralgias in both shoulders.
5 months after initiation the patient showed a lipase increase of 559 U/l, after which we interrupted the immunotherapy. Two weeks later the lipase count increased up to 1300 U/l without any symptoms of a pancreatitis. An abdominal sonography and an abdominal MRI did no show any signs of an acute pancreatitis.
We decided to withdraw the immunotherapy due to multiple immune related adverse events (irAE). The patient did also lose 10 kg body weight after initiation of the lipase increase. One month after the lipase increase onset the lipase counts nearly resolved, but the patient developed a hyperglykemia with decreased insulin. Since then he needs insulin substitution.
Patients with one irAE are more likely to develop another irAE, so that patients should be closely monitored. Asymptomatic lipase increases are common (2,3 %, Su Q. et al J Immunol Res. 2018), however a treatment without any clinical signs for a pancreatitis is not required. The development of diabetes mellitus in this case could either occur as a consequence of an occult pancreatitis (diabetes type 3) or as an new irAE (diabetes type 1). Either way glucocorticosteroids would not be recommended (Stamatouli AM et al. Diabetes 2018). As it is an endocrinological irAE, substitution therapy is needed.
