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CPE-008 · synthetic case ADR-FX-11
Checkpoint inhibitor, headache and sodium 129
An immune-related adverse event to look for.
Purpose: An immune-related adverse event to look for.
Inputs the engine received
Chemistry and vitals
- Age
- 66 years
- Sodium
- 129 mmol/L
Symptoms and signs
- Fatigue
- Yes
- Headache
- Yes
Exposures, history and context
- Immune checkpoint inhibitor treatment
- Yes
What the engine reports
Hypophysitis and primary adrenalitis are recognized immune-related adverse events. Screen cortisol, ACTH, TSH, free T4 and sodium/potassium, and tell the oncology team.
Detected clinical pattern
Checkpoint Inhibitor — Endocrine Screening Prompt
Symptoms on a checkpoint inhibitor justify screening for hypophysitis and adrenalitis.
Recommended next steps
For physician consideration. Urgent review always comes first.
- 1Order an 8 am cortisol with ACTH; add renin and aldosterone when primary insufficiency is suspected.Endocrine Society 2016.
- 2Screen cortisol, ACTH, TSH, free T4, sodium and potassium; inform oncology.ASCO 2021.
Missing information
- 8 am cortisol and ACTH.
Evidence and rule trace · 2 rules
AI-01Clinical and laboratory pattern that justifies testing
Inputs: sodium 129 · fatigue
Screening opportunity: measure an 8 am cortisol with ACTH.
AI-11Immune checkpoint inhibitor
Inputs: immune checkpoint inhibitor · fatigue · headache · sodium 129
Screen for hypophysitis and primary adrenalitis.
Evidence
- EV-ES-PAI-2016 · Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389.
- EV-HUSEBYE-2014 · Husebye ES, Allolio B, Arlt W, et al. Consensus statement on the diagnosis, treatment and follow-up of patients with primary adrenal insufficiency. J Intern Med. 2014;275(2):104-115.
- EV-ASCO-IRAE-2021 · Schneider BJ, Naidoo J, Santomasso BD, et al. Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update. J Clin Oncol. 2021;39(36):4073-4126.
Physician adjudication required. Clinical decision support for physician review. This output identifies laboratory patterns and safety situations. It does not diagnose adrenal insufficiency, name a glucocorticoid dose, or replace emergency treatment. Physician adjudication is required.
Change the values
The same engine, starting from this case. Change any value and watch the pattern and the rule trace react.
Cortisol testing
- <5 very likely
- 5–14.9 indeterminate
- ≥15 unlikely
46 pg/mL is assumed when empty.
Chemistry and vitals
Symptoms and signs
Exposures, history and context
More adrenal cases
ADR-FX-01
Low sodium, high potassium, weight loss and nausea
A 44-year-old with hyperpigmented scars.
ADR-FX-02
Hyperpigmentation and fatigue
No labs yet.
ADR-FX-03
Salt craving and dizziness on standing
Low sodium.
ADR-FX-04
Cortisol 2.1 with ACTH 180
Low cortisol and high ACTH: a primary pattern.
ADR-FX-05
Morning cortisol 9 µg/dL
Indeterminate.
ADR-FX-06
Morning cortisol 17 µg/dL
Unlikely.
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