Introduction Immune checkpoint inhibitors (ICI) have been approved for use in cancer therapy for malignant melanoma, non-small cell lung cancer, and renal cell carcinoma in the last decade. Since their inception, immune-related adverse events (irAEs) have been well documented. We present a patient who developed 2 irAEs - grade 1 irAE during therapy and grade 3 irAE five months after completion of anti-CTLA-4 (Ipilimumab) and anti-PD-1 antibody (Nivolumab) therapy. Case description Our patient is a 65-year-old woman who was diagnosed in 2019 with Melanoma over the left knee which was resected in her home country. During follow-up here, she was started on immunotherapy with Ipilimumab and Nivolumab for metastatic disease. Her baseline labs including TFTs were normal before initiation of therapy. During treatment after 4 infusions, she developed hypothyroidism. At that time she was tolerating treatment well. Levothyroxine was initiated for this grade 1 irAE with the continuation of immunotherapy. She decided to move to her home country with a plan to pursue further immunotherapy upon her return. 7 months after discontinuation of therapy, the patient presented to our hospital with nausea, vomiting, and dizziness for 2 months. She was hypotensive and minimally responsive to intravenous fluids. Labs drawn were remarkable for hypothyroidism. Further workup demonstrated adrenal insufficiency with morning cortisol of 0.1 μg/dL and ACTH of <1.5 pg/ml. Pituitary hormones were within normal range except for elevated prolactin. A contrast-enhanced MRI of the pituitary was negative for any enlargement or mass. She was diagnosed with secondary adrenal insufficiency and managed with stress-dose corticosteroids with a resolution of symptoms. We were able to ascertain that our patient developed grade 3 irAE almost 5 months after her last immunotherapy. Discussion Cancer immunotherapy is associated with endocrinopathies such as hypophysitis, hypothyroidism, and adrenal insufficiency. As per a review done by González-Rodríguez E et al it has been found that the median time of onset from initiation for endocrine AEs was 7 - 20 weeks due to Ipilimumab and 11 weeks due to Nivolumab. In patients who received combined therapy, as per a retrospective study done by Nguyen et al, the median time from ICI administration to the diagnosis of immune-related hypophysitis was 35.8 weeks. In 2019, Ohara N reported a case of a patient with lung adenocarcinoma who developed isolated ACTH deficiency 4 months after discontinuation of Nivolumab therapy. Our patient developed two irAEs - during and after completion of immunotherapy. Symptoms can often be generalized and overlap with those of cancer progression making it difficult to diagnose. Our case highlights the need for continued surveillance of these patients by physicians probably even months after completion. Presentation: No date and time listed

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Background Kidney dysfunction is a prevalent disease that leads to many complications over time, such as hypertension, heart disease, and death. ACEI/ARBs are known to be renoprotective. However, few studies describe the association between ACEI/ARB use and kidney dysfunction in patients with SARS-CoV-2 infection. Purpose To explore the association between patients with SARS-CoV-2 and kidney dysfunction in patients taking an ACEI/ARB. We hypothesize a negative association between patients with SARS-CoV-2 taking an ACEI/ARB and kidney dysfunction. Methods A retrospective query between March 2020 and April 2021 was performed in patients 18 years and older who tested positive for SARS-CoV-2 using a polymerase chain reaction test. Patients were divided into two groups: kidney dysfunction and no kidney dysfunction. Kidney dysfunction was defined as any diagnosis of chronic kidney disease or acute kidney injury. Primary outcomes were all-cause mortality and hospitalization rate. Secondary outcomes included myocardial infarction (MI), hypotension, intubation, vasopressor use, ventricular tachycardia, and ventricular fibrillation. We used multivariate logistic regression to adjust for baseline characteristics. Results We identified 996 patients with kidney dysfunction and 22,106 without kidney dysfunction who tested positive for SARS-CoV-2. The incidence was 258 (25.9%) for ACEI/ARB use in patients with kidney dysfunction. Adjusted odds ratio (OR) for patients with kidney dysfunction was 5.705 (95% Confidence Interval [CI]: 4.554–7.146; p<0.001) for hospitalization, 0.895 (95% CI: 0.707–1.135; p<0.361) for patients taking ACEI/ARB, and 0.529 (95% CI: 0.333–0.838; <0.007) for mortality in patients with kidney dysfunction who took ACEI/ARB. All secondary outcomes had significantly greater adjusted OR (p<0.001), except for MI (p<0.339), ventricular tachycardia (p<0.697), and ventricular fibrillation (p<0.060). Conclusion To date, the benefits of ACEI/ARB in SARS-CoV-2 patients have been controversial. While ACEI/ARB is known to have renoprotective properties, we did not find a significant association between ACEI/ARB and kidney dysfunction in patients with SARS-CoV-2. However, we found the use of ACEI/ARB in patients with kidney dysfunction to be associated with lower mortality. Therefore, clinicians should continue using this medication for its mortality benefits in patients with kidney dysfunction and its cardioprotective effects. Funding Acknowledgement Type of funding sources: None.

Introduction Hyperparathyroid crisis is a rare endocrine emergency with a high mortality. Primary hyperparathyroidism (PHP) can present as severe hypercalcemia. There are very few cases documented in literature of patients with concomitant SLE and PHP. We present a case of hypercalcemic crisis in a patient with untreated primary hyperparathyroidism with a history of SLE. Case description A 46 year old woman was found to have hypercalcemia of 12.9 mg/dl on routine lab work. Her medical history is significant for SLE (diagnosed 9 years prior) and osteoarthritis. She had no physical complaints. Further workup confirmed primary hyperparathyroidism with PTH of 322.8 pg/ml and findings consistent with parathyroid adenoma on Sestamibi scintigraphy. Parathyroidectomy was strongly recommended however the patient refused. She was then offered medical management but did not show up for any follow up appointments. Two years later, she presented to the emergency department with altered mentation, lethargy, poor oral intake and abdominal pain for 2 days. She was found to have severe hypercalcemia with a serum calcium of > 24.8 mg/dl and was in acute renal failure. On admission, EKG changes suggestive of pseudoinfarct pattern from severe hypercalcemia were present. She was managed in the intensive care unit with intravenous hydration, calcitonin, zoledronic acid and hemodialysis. Shortly after initiation of hemodialysis, the patient succumbed to a cardiac arrest. Conclusion Hyperparathyroid crisis when untreated has a 100% mortality rate. Early management with surgical intervention is the only confirmed cure for PHP. There are only 18 cases reported in literature of hypercalcemia in SLE. Mechanisms involved are believed to be stimulatory PTH antibodies, PTHrP and osteoclastic activity due to inflammatory cytokines. To our best knowledge this is the 6th case report of a patient with concomitant SLE and PHP. A prospective study by Norman et. al 1 done in 10000 PHP patients demonstrated a Gaussian distribution with the average calcium concentration being 10.9 ± 0.6 mg/dL and the average parathyroid hormone concentration being 105.8 ± 48 pg/ml . Her baseline calcium at diagnosis was 13mg/dl and intact PTH was 322.8 pg/ml which is higher than seen in the normograms as per the study. In our patient, we believe SLE could have exacerbated the hypercalcemia caused by PHP. It is important to perform further studies to identify if any association exists between the two conditions. Physicians must recognize their concomitant occurrence as prompt management of hypercalcemia becomes even more crucial in these cases. References: 1) Norman J, Goodman A, Politz D. Calcium, parathyroid hormone, and vitamin D in patients with primary hyperparathyroidism: normograms developed from 10,000 cases. Endocr Pract. 2011 May-Jun;17(3): 384-94. doi: 10.4158/EP09346. OR. PMID: 21134884. Presentation: No date and time listed