Pembrolizumab-Induced Adrenal Insufficiency Presenting Eight Months After Cessation of Treatment.

Pembrolizumab is a monoclonal antibody that functions as an immune checkpoint inhibitor. It is an FDA-approved immunotherapy used to treat various malignancies. With its wide use in cancer therapy, there are many known side effects. It is a common cause of endocrinopathies such as thyroid disease and adrenal insufficiency (AI). AI has been most commonly reported during active treatment cycles with pembrolizumab, as well as quickly after the termination of treatment. However, we describe a case of pembrolizumab-induced AI with an onset at eight months following the discontinuation of treatment and discuss prompt treatment when AI is diagnosed.

A Delayed Presentation of Bilateral Adrenal Hemorrhage Secondary to COVID-19.

Background/Objective: Bilateral adrenal hemorrhage is a rare cause of adrenal insufficiency. Cases have been reported of acute adrenal crisis with bilateral adrenal hemorrhage during acute coronavirus disease of 2019 (COVID-19). Our objective was to report a delayed presentation of acute adrenal crisis with bilateral adrenal hemorrhage 2 months after COVID-19. Case Report: An 89-year-old man who was hospitalized for COVID-19 pneumonia 2 months prior presented with lethargy. He was disorientated and hypotensive to 70/50 mm Hg without improvement with intravenous fluids. According to his family, since his previous hospitalization for COVID-19, his mental status had continued to deteriorate, and he was no longer able to perform activities of daily living. A computed tomography scan of the abdomen revealed bilateral heterogeneous enlargement of the adrenal glands. Laboratory values were significant for an am cortisol level of 8.42 mcg/dL, a sodium level of 134 mEq/L, and a bicarbonate level of 17 mEq/L. He was treated intravenously with hydrocortisone 100 mg and showed rapid improvement. Discussion: It has been shown that COVID-19 disease may cause an increased risk of bleeding or thromboembolism. The exact frequency of bilateral adrenal hemorrhage secondary to COVID-19 is unknown. Although there are a handful of cases reported, there are none to our knowledge with a delayed presentation, as exhibited in our patient. Conclusion: The patient's presentation was consistent with acute adrenal crisis due to bilateral adrenal hemorrhage from prior COVID-19 disease. We aimed to highlight the importance of clinicians being aware of adrenal hemorrhage and adrenal insufficiency as a possible delayed consequence in patients with a history of COVID-19.

Sleep Disorders and Cardio-Renal Disease: Implications for Minority Populations.

Obesity is a major public health problem that is reaching pandemic proportion. Currently two thirds of the American population is either overweight or obese and worldwide, 39% of the population is overweight and 13% are considered obese [1,2]. This rapid rise in obesity is associated with increased in diabetes mellitus type 2 (DM2), hypertension (HTN), chronic kidney disease (CKD) and cardiovascular diseases (CVD), the major killer of adults in the USA. Parallel to this epidemic is the rapid rise of sleep disorders such as Obstructive Sleep Apnea (OSA). These disorders lead to increased morbidity and mortality and generally go undiagnosed and undertreated, particularly among minority groups. Accumulating evidence indicates common pathophysiologic background underlying all of these related disorders. Among these include: increased inflammation, increased oxidative stress, endothelial dysfunction, dyslipidemia and hypercoagulability. We discuss the rising epidemic of sleep disorders and its interrelationship with DM2, HTN, CVD and renal disease highlighting the racial disparity in diagnosis and treatment of these disorders that disproportionately affects minority populations. We also discuss the various treatment modalities and the cutting edge developments in this field.