Abdominal pain as an initial symptom of isolated ACTH deficiency induced by nivolumab in a patient with malignant mesothelioma

Our plain-English summary of Abdominal pain as an initial symptom of isolated ACTH deficiency induced by nivolumab in a patient with malignant mesothelioma, by K. Hata, C. Sakaguchi, M. Tsuchiya, et al (BMJ Case Reports, 2021).

The study

• Authors: K. Hata, C. Sakaguchi, M. Tsuchiya, Y. Nagasaka
• Journal: BMJ Case Reports
• Published: 2021;14(7)
• Type of article: Case report
• Cited by: 3 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Used for a wide range of cancers, nivolumab has been reported to cause immune-related adverse events, including isolated adrenocorticotropic hormone deficiency (IAD). We report an 81-year-old woman with malignant mesothelioma who presented with abdominal pain after eight courses of nivolumab therapy, leading to the diagnosis of nivolumab-induced IAD. We should consider adrenal insufficiency (AI) when a patient on nivolumab complains of abdominal pain and has no other explanatory findings. Infusion-resistant hypotension and hyponatraemia can further suggest AI.

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In plain English

This case report described an 81-year-old woman, treated at a hospital in Kyoto, Japan, with stage IIIB malignant mesothelioma. The patient developed a hormone deficiency as a side effect of the cancer drug nivolumab. The article did not discuss asbestos exposure and did not say where in the body the mesothelioma was. After chemotherapy, the patient started nivolumab (240 mg every 2 weeks) in October 2018. After the eighth course and surgery for sigmoid colon cancer, the patient had mild abdominal pain for 2 months, and a CT scan found no cause. After the 12th course the pain worsened. The patient also had fatigue, low blood sodium, and low blood pressure that stayed around 100/80 mm Hg despite 1.5 litres of saline. Tests showed low ACTH (0.75 pmol/L) and cortisol (34.5 nmol/L). The authors diagnosed isolated ACTH deficiency caused by nivolumab. Nivolumab was stopped, oral hydrocortisone 15 mg daily was started, and all symptoms resolved by the 11th hospital day. In the authors' table of 29 published nivolumab-related cases, including this one, only this patient had abdominal pain. The authors concluded that adrenal insufficiency should be considered when a patient on nivolumab has unexplained abdominal pain.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (single patient), with a table reviewing published case reports of nivolumab-related isolated ACTH deficiency
• Who was studied: one 81-year-old woman with a history of Graves' disease, diagnosed with stage IIIB malignant mesothelioma in 2017, treated at Rakuwakai Otowa Hospital, Kyoto, Japan
• Exposure: the cancer drug nivolumab, 240 mg every 2 weeks, started October 2018 after 10 courses of carboplatin and pemetrexed chemotherapy. Asbestos exposure is not discussed in the article.
• Main results:
  • After the eighth nivolumab course and surgery for sigmoid colon cancer, the patient had mild intermittent abdominal pain lasting 2 months. A CT scan showed no cause.
  • After the 12th course, the patient's blood pressure stayed around 100/80 mm Hg despite 1.5 litres of intravenous saline. The patient also had hyponatraemia (low blood sodium).
  • In this patient, early-morning blood tests showed low ACTH (0.75 pmol/L) and low cortisol (34.5 nmol/L). The authors diagnosed isolated ACTH deficiency due to nivolumab.
  • Nivolumab was stopped and oral hydrocortisone 15 mg daily was started on the seventh hospital day. All of the patient's symptoms had resolved by the 11th hospital day.
  • Among 29 patients with nivolumab-related isolated ACTH deficiency (published cases plus this one), only the present case had abdominal pain.
• The authors' conclusion: The authors concluded that adrenal insufficiency should be considered as a possible diagnosis when a patient on nivolumab has abdominal pain with no explanation on imaging tests.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Nivolumab (Opdivo), Mesothelioma, Immune-Related Adverse Events.

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• Benign Multicystic Peritoneal Mesothelioma (BMPM) as a rare cause of abdominal pain in a young male: case report and review of the literature — S. Gussago, P. Spina, et al. (2019)
• Multicystic benign mesothelioma of the pelvic peritoneum presenting as acute abdominal pain in a young woman — J.H. Hong, S. Jeon, et al. (2013)
• A Mesothelial Inclusion Cyst Presenting in a 40-Year-Old Woman as Abdominal Pain and Bloating - A Rare Diagnosis — S. Canadas, R. Fernandes, et al. (2020)
• Benign Multicystic Peritoneal Mesothelioma (BMPM) as a rare cause of abdominal pain: a case report and review of the literature — H.B. Hassine, M. Touati, et al. (2025)

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