Challenges in autoimmune polyendocrine syndrome type 2 with the full triad induced by anti-programmed cell death 1: a case report and review of the literature

Sintilimab-induced diabetes mellitus and thyroid dysfunction in patient with gastric adenocarcinoma: A case report and literature review

RATIONALE

Immune checkpoint inhibitors bring hope to cancer patients but may also lead to severe immune-related adverse events (irAEs). Although irAEs during treatment are well-characterized, delayed immune-related events (DIRE) remain underreported. Here, we report a case of sintilimab-induced delayed immune-related diabetes mellitus, accompanied by ICI-related thyroid disease (ICI-TD). Cases involving both ICI-TD and ICI-related diabetes mellitus (ICI-DM) are also relatively rare. This study systematically aggregates dual endocrine irAEs to provide valuable insights for clinical practice.

PATIENT CONCERNS

A 60-year-old Chinese male diagnosed with gastric adenocarcinoma received a multimodal treatment regimen consisting of sintilimab, chemotherapy, and apatinib. He completed 3 cycles of chemotherapy and 4 cycles of sintilimab. Due to disease progression, sintilimab was discontinued, but apatinib was continued for an additional 1 month. No further antitumor therapy was administered afterward. Four months later, he was admitted to the emergency department due to persistent nausea, vomiting, and abdominal pain.

DIAGNOSES

Thyroid dysfunction induced by sintilimab was identified during treatment. His laboratory tests contributed to the diagnosis of diabetes ketoacidosis. Fulminant type 1 diabetes mellitus attributed to sintilimab met diagnostic criteria: plasma glucose 42.01 mmol/L, glycated hemoglobin 7.5%, C-peptide <0.02 µg/L, and negative islet autoantibodies.

INTERVENTIONS

Levothyroxine replacement therapy was initiated for hypothyroidism, whereas diabetes ketoacidosis during hospitalization required intensive insulin therapy combined with fluid resuscitation.

OUTCOMES

The patient exhibited persistent blood glucose fluctuations during hospitalization, including 2 hypoglycemic episodes. Post-treatment stabilization required basal-bolus insulin at discharge, with continued levothyroxine for hypothyroidism.

LESSONS

We report a rare case of concurrent ICI-TD and ICI-DM following sintilimab therapy. This case underscores the potential for DIRE, with onset occurring months posttreatment. Combined with a systematic review of existing cases, this study provides critical insights into surveillance strategies and pathogenesis of irAEs.

Delayed diagnosis of the full triad autoimmune polyendocrine syndrome type 2 with adrenal crisis: a case report and literature review

Background

Autoimmune polyendocrine syndrome type 2 (APS-2) is a rare disorder characterized by autoimmune damage to multiple endocrine glands and typically involves primary adrenal insufficiency (PAI), autoimmune thyroid disease (AITD), and type 1 diabetes mellitus (T1DM). Clinical presentations that feature the full triad alongside adrenal crisis (AC) are rare, with only four such cases reported globally. While AC is the most life-threatening acute complication of APS-2, its pathogenesis is complex and incompletely understood. While there are multiple potential triggers, the role of exogenous substances such as traditional Chinese medicine [TCM] has not been systematically examined.

Case presentation

A 69-year-old female was hospitalized with a 9-year history of increasing fatigue, which had recently worsened due to high fever, anorexia, and vomiting lasting 2 days. She has previously been diagnosed with T1DM (nine years prior) and AITD (five years prior). Four years earlier, she underwent thymoma resection. Three years before admission, she self-administered an unknown TCM remedy that coincided with increased fatigue and mucocutaneous hyperpigmentation. On admission, she was in hypovolemic shock and severe hyponatremia (118.0 mmol/L). Laboratory tests revealed low basal cortisol (2.38 μg/dL) and markedly elevated adrenocorticotropic hormone (>1250 pg/mL). An adrenocorticotropic hormone stimulation test confirmed non-responsive adrenal function, indicating PAI. Together with her medical history and positive antibody profile, APS-2 with AC was diagnosed. She responded well to high-dose intravenous glucocorticoid therapy, sodium supplementation, and symptomatic management. Although persistent hyponatremia recurred following discharge, it resolved following fludrocortisone acetate supplementation, and her condition remained stable at the last follow-up.

Conclusion

We report the fifth case of full-triad APS-2 with AC and document a 9-year diagnostic delay due to non-specific symptoms with asynchronous multi-glandular involvement. Thyroxine replacement therapy and potential TCM-induced changes may have aggravated cortisol metabolism and immune imbalances, hastening adrenal failure. Clinicians should implement stepwise organ-function monitoring in patients with any single-gland autoimmune disease, maintain vigilance for exogenous medication use, and implement multidisciplinary management strategies to mitigate the risk of AC. This case provides critical insights into both the pathogenesis and clinical management of APS-2.

Cognitive Impairment Caused by Isolated Adrenocorticotropic Hormone Deficiency Mimicking Dementia with Lewy Bodies

A 73-year-old man who presented with nonspecific general symptoms and cognitive impairment was initially diagnosed with mild cognitive impairment due to dementia with Lewy bodies (DLB) based on a reduced blood flow in the parietal and occipital lobes on single-photon emission computed tomography (SPECT) imaging. However, the patient later presented with hyponatremia and hypoglycemia, leading to impaired consciousness, and was diagnosed with isolated adrenocorticotropic hormone deficiency (IAD). Hydrocortisone treatment improved the blood test scores and general symptoms, including cognitive impairment. IAD may show a DLB-like presentation on cerebral blood flow SPECT; therefore, caution is required for the correct diagnosis of IAD.