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Endocrine disorders: case report A 62-year-old man developed hypothyroidism during treatment with axitinib for metastatic renal cell carcinoma (RCC), hypophysitis leading to secondary adrenal insufficiency during treatment nivolumab for RCC and thyroid hormone abnormalities during treatment with levothyroxine sodium. It was possible that an excessive levothyroxine sodium exacerbated adrenal insufficiency [routes and duration of treatments to reactions onset not stated; not all dosages stated]. The man was diagnosed with RCC in July 2013 and metastasized to the brain in October 2015. He received brain stereotactic radiation therapy followed by axitinib. However, he developed hypothyroidism due to axitinib. The man was started on treatment with levothyroxine sodium [levothyroxine] in February 2016. In April 2018, a CT scan revealed progressive disease, and he started receiving nivolumab 3 mg/kg every 2 weeks. After 8 courses of nivolumab, his cortisol and adrenocorticotropic hormone (ACTH) levels were suddenly elevated without any inciting causes. In August 2018, he was admitted for endocrinological investigation. On admission, laboratory investigations revealed following results: mild anaemia, normal levels of plasma cortisol, ACTH, prolactin and luteinizing hormone, low levels of TSH, free tri-iodothyronine (T3), growth hormone, insulin-like growth factor-1 and testosterone and elevated levels of thyroxin and follicle-stimulating hormone. However, in the early morning on day 2, his serum cortisol and ACTH levels fell down sharply without vital sign changes or subjective symptoms. He was diagnosed with suspected secondary adrenal insufficiency and was treated with hydrocortisone replacement. Brain MRI showed no abnormal findings in the pituitary gland. A TSH response to thyrotropinreleasing hormone was decreased due to levothyroxine sodium treatment. Cortisol did not respond to elevated levels of endogenous ACTH, but responded to exogenous ACTH during a rapid ACTH stimulation test. Therefore, it was considered that his pituitary gland secreted a biologically inactive ACTH, and recent-onset hypothalamic adrenal insufficiency was suspected. Based on his clinical presentation, he was diagnosed with secondary adrenal insufficiency following nivolumab-induced hypophysitis. Thyroid hormone abnormalities were considered due to excessive levothyroxine sodium and low T3 syndrome. His levothyroxine sodium dose was reduced due to a possibility that an excessive levothyroxine sodium might have exacerbated adrenal insufficiency. He was continued on hydrocortisone and levothyroxine replacement. He was discharged after 12 days of admission. He was continued on nivolumab with hormonal replacement therapy. His hormonal status and pituitary MRI findings was unchanged 4 months after the discharge. Author comment: "Herein we report a case of nivolumabinduced hypophysitis leading to secondary adrenal insufficiency". "Thyroid hormone abnormalities were considered because of low T3 syndrome and excessive [levothyroxine sodium]." Sek