通讯作者: 贾贝, jam.es2009@163.com

DOI：10.12201/bmr.202411.00022

Sintilimab-induced Diabetes Ketoacidosis with multiple organ immune related adverse reactions:A Clinical Case

• 摘要：一例60岁男性晚期胸下段食管鳞癌患者，既往无糖尿病等慢性病史，使用免疫联合化疗方案：信迪利单抗联合紫杉醇和顺铂。患者在第4周期治疗后2天，突发昏迷伴休克，急诊紧急处理后转重症监护室（Intensive Care Unit，ICU），予血管活性药物升压、胰岛素降糖、生理盐水扩容等处理，同时完善相关检测，确诊糖尿病酮症酸中毒（Diabetic ketoacidosis，DKA）；心衰心梗标志物提示心肌损伤，血生化提示急性肾损伤（acute kidney injury，AKI）、肝功能异常。ICU开始连续静脉-静脉血液滤过（continuous veno-venous hemofiltration，CVVH）维持患者肾脏功能，同时进行保肝治疗，考虑病情危重升级抗感染治疗。患者入院第2天血糖逐渐下降至可控范围，心肌损伤、肝损伤、肾损伤、肌损伤检测到峰值，并出现电解质异常。ICU考虑免疫相关性心肌损伤，予甲泼尼龙并继续对症支持治疗，患者脱离危重状态，各项指标逐渐转归。15天后患者病情平稳，血糖11.3mmol/L，转氨酶恢复正常，心衰心梗标志物三项回落，仍需肾替代治疗，转综合医院继续治疗。半年后就诊随访，患者空腹血糖11.81mmol/L，血肌酐略高，心梗心衰标志物基本恢复正常，未再使用免疫治疗。

  关键词： PD-1抑制剂；信迪利单抗；免疫相关不良反应；糖尿病酮症酸中毒；肝损伤；心肌炎；肌炎；急性肾功能不全

   

  Abstract: We present a 60-year-old male patient with advanced squamous cell carcinoma of the lower thoracic esophagus, accompanied by multiple metastasis,he denied diabetes and other chronic medical history. The Oncologyl department established an immunotherapy combined with chemotherapy regimen : sindelizumab in combination with paclitaxel and cisplatin. Two days after the 4th cycle of treatment, the patient suddenly went into shock coma at the time of admission, unconscious with cold and wet limbs, undetectable blood pressure and less urine. His rapid blood glucose determination showed >33.3 mol·L-1, arterial blood gas analysis suggested acidosis. The patient was then transferred to ICU and treated with vasoactive drugs, insulin and normal saline for volume expansion. His further blood biochemical test showed GLU 58.63 mmol·L-1, urinalysis GLU was 4 + , and urinalysis KET was 2 + , thus the diagnosis of Diabetic ketoacidosis（DKA） was confirmed. AST 557.4 U·L-1 and ALT 100.7 U·L-1 indicated he had a abnormal liver function. The patient in ICU was treated with liver protection and anti-infection therapy,as well as CVVH to maintain the renal function. On the second day after admission, his blood glucose gradually decreased to the controllable range, and the peak values of myocardial injury, liver injury, kidney injury, muscle injury and electrolyte abnormality were detected. He also had an electrolyte disturbance.Considering he may had an immune-related myocardial injury,?he was treated with methylprednisolone 140 mg·d-1,meanwhile symptomatic and supportive treatment.After 15 days, the patients condition was stable, blood glucose was 11.3 mmol·L-1, transaminase returned to normal, NT-proBNP 683pmol·L-1,hs-cTnT 1.01ng·mL-1,Mb 1014ng·mL-1. 6 months later following up,the patient’s fasting blood glucose and serum creatinine were 11.81 mmol·L-1 and 111.2 μmol·L-1 respectively,the markers of heart failure in MI returned to normal.?He is no longer on immunotherapy

  Key words: PD-1?Inhibitor；Sintilimab；Immune-related adverse reactions；Diabetes ketoacidosis；Liver injury；Myocarditis；Myositis；Acute renal insufficiency

  提交时间：2024-11-11

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• 序号	提交日期	编号	操作
  1	2024-09-29	bmr.202411.00022V1	下载

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