Interferon has also been implicated in causing thyroid dysfunction. antithyroid medications and systemic steroids resulting in an improvement in thyroid function testing and symptoms. Background Novel immunotherapy agents, nivolumab and ipilimumab, have the capacity to effectively eliminate immunogenic tumours such as melanoma through the use of immune checkpoints.1C3 Immune-checkpoint inhibitor therapies are evolving to be the mainstay of therapy in BRAF-mutated advanced melanoma.4 Ipilimumab is a monoclonal antibody against CTLA-4, boosting T-cell activation and proliferation.5 Nivolumab is a human programmed death receptor-1 (PD-1) blocking antibody, which also creates a negative regulatory T-cell response.6 Through the use of alternative checkpoints, these brokers provide distinct clinical activity in treatment of advanced melanoma compared with monotherapy, as highlighted by Wolchock diagnostic point scale for thyroid storm, our patient scored 85. By this scoring system, a score higher than 45 is usually suggestive of thyroid storm.1 The patient was admitted to the intensive care unit R-10015 (ICU), with endocrinology and oncology consultation. Investigations Initial complete blood count, basic metabolic panel, lipase and urinalysis were all R-10015 normal. Urine pregnancy test was negative. Blood cultures were obtained and unfavorable at 48?h. An ECG showed sinus tachycardia. R-10015 The patient’s thyroid function assessments on the day of presentation were: thyroid stimulating hormone 0.062?U/mL, free thyroxine 4.0?ng/dL and free triiodothyronine 6.4?ng/dL (normal range 1.5C3.5?ng/dL). Her historical thyroid function assessments after receiving interferon therapy but prior to initiation of treatment with nivolumab and ipilimumab were: thyroid stimulating hormone 3.289?U/mL and free thyroxine 0.7?ng/dL. Thyroid peroxidase and thyroid stimulating immunoglobulin levels were within normal range. A thyroid ultrasound revealed diffuse thyroid heterogeneity consistent with non-specific thyroiditis. Radioactive iodine uptake study was not performed due to the patient having had a recent CT scan with intravenous contrast. Chest X-ray (CXR) was unfavorable. The patient improved symptomatically from her initial presentation and was discharged home the next day from the intensive care unit (ICU). The patient returned to the emergency department within 24?h of initial discharge with re-emergence of her symptoms including nausea, Rabbit Polyclonal to Tau (phospho-Thr534/217) vomiting, agitation and anxiety. She was febrile to 38.9C (102 Fahrenheit) with tachycardia to 120. All other vital signs were stable. Physical examination remained non-focal. A chest X-ray, urinalysis, basic metabolic panel and complete blood count with differential were unremarkable. Repeat thyroid stimulating hormone was 0.043?U/mL. Free thyroxine improved to 2.1?ng/dL. Around the Burch diagnostic point scale for thyroid storm, our patient scored 65. The patient was admitted to the progressive care unit for concerns of unresolved thyroid storm, with endocrinology and oncology consultation. Investigations were broadened to include a thorough infectious work up that included lactate within normal limits, a negative respiratory viral panel, a negative rapid streptococcus, unfavorable urine gonorrhoea and unfavorable chlamydia PCR. Lumbar puncture was performed and resultant Gram stain, culture, cell count, protein and glucose were all normal. Infectious disease was consulted. Cryptococcal antigen, assay, cytomegalovirus antigen, histoplasma antigen, HIV and mono heterophile antibody all resulted unfavorable. Final blood and urine culture results were unfavorable. Repeat blood cultures were unfavorable at 48?h. Urine culture was unfavorable. CT of the chest with intravenous contrast revealed no acute process, most notably no pulmonary embolism. Differential diagnosis The patient had signs and symptoms of thyroid storm based on the diagnostic criteria for thyroid storm developed by Burch can aid in confirming the diagnosis. This scale system assigns points in the categories of thermoregulatory dysfunction, central nervous system effects, gastrointestinal-hepatic dysfunction, cardiovascular dysfunction and precipitant history. Scores are totalled and a score of 45 or greater is usually highly suggestive of thyroid storm.1 Our patient’s score totalled 85 on initial presentation and 65 on readmission. It is important to point out that our patient was treated with interferon for 1?12 months prior to the initiation of nivolumab and ipilimumab. Interferon has also been implicated in causing thyroid dysfunction. However, our patient had.