Stage IVA lung squamous cell carcinoma with immune-checkpoint-inhibitor-associated Graves thyroid storm

What happened, in summary

This man in his 80s had Stage IVA squamous cell carcinoma of the lung along with rheumatoid arthritis, diabetes mellitus, and hypertension. He was receiving combination immune checkpoint inhibitor therapy with nivolumab and ipilimumab, with his most recent dose 25 days before hospitalization. He came to the hospital after falling and striking his left chest against a stone wall. CT showed fractures of the left 5th through 11th ribs, and he was admitted for pain control because mobility was limited. Pain management included intravenous fentanyl, oral loxoprofen sodium, and a tramadol hydrochloride/acetaminophen combination, but pain remained difficult to control. On hospital day 5, he developed delirium and tachycardic atrial fibrillation. Fever followed on day 7. Thyroid testing showed suppressed TSH and elevated FT3 and FT4, and his Burch-Wartofsky thyroid storm score was 75, strongly supporting thyroid storm. Ultrasound did not show thyroid adenoma or multinodular goiter. Because TSAb/TRAb antibodies were strongly positive, the team favored Graves disease associated with immune checkpoint inhibitor therapy rather than ordinary destructive thyroiditis. Treatment included landiolol for rate control plus hydrocortisone, potassium iodide, and high-dose thiamazole. His symptoms improved quickly. When thiamazole and potassium iodide were stopped, fever, delirium, and tachycardic atrial fibrillation returned; restarting them again improved the crisis. On day 15, his condition stabilized enough for transfer to the hospital where he was receiving lung-cancer care. He died of progressive lung cancer about 2 months later. The cancer response itself was not the focus of this admission; the case mainly showed how immunotherapy can trigger a rare Graves-type thyroid storm requiring antithyroid medication, steroid therapy, and careful monitoring during an already fragile cancer course.