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Various toxicities: case report A34-year-old man developed hepatitis, gastritis and vitiligo during treatment with ipilimumab and nivolumab for malignant melanoma, and he developed hypohidrosis during nivolumab monotherapy. The man, whose medical history was notable for malignant melanoma, presented with complaints of markedly decreased sweating. Seven years prior to his current presentation, he had been diagnosed with stage III malignant melanoma, which was subsequently excised. Thereafter, he started receiving ipilimumab 3 mg/kg and nivolumab 1 mg/kg every 3 weeks [routes not stated]. However, 6 weeks following treatment initiation, he noticed a depigmented patch on the forearm, which was clinically compatible with vitiligo, and after completing cycle 3 of ipilimumab and nivolumab, he developed nausea and vomiting, which progressed to several episodes of haematemesis. Therefore, oesophagogastroduodenoscopy was performed, which revealed gastritis. The man was treated with esomeprazole, prednisone and ranitidine. He was also found to have elevated transaminases (ALT 390 U/L and AST 162 U/L), leading to the diagnosis of immune-mediated hepatitis. Hence, ipilimumab and nivolumab were withheld. After 2 months, tests revealed interval improvement in hilar and splenic masses; hence, nivolumab monotherapy was resumed. The disease remained stable on nivolumab monotherapy for over 1 year. Later, at the time of his current presentation, he reported decreased sweating for 2 months. This was particularly remarkable since he had an active lifestyle, which involved participation in multiple individual and team sports. He stated that prior to symptomatic onset, he would sweat profusely, to the point of ’seeing beads of sweat on his arms’, but now, he only sweat at the base of the palms, dorsal fingers, lower back and forehead. He endorsed accompanying dyspnoea and associated heat intolerance. Submersion in water and swimming improved his symptoms. Physical examination showed several depigmented patches on his extremities, clinically compatible with immunotherapy-associated vitiligo. The patches were accentuated on Wood’s lamp examination. A thermal starch-iodine test was performed on his forearm and axilla to further evaluate his complaint of decreased sweating. Results revealed that while he was able to produce axillary sweat, the volume of sweat produced could not be determined adequately; hence, hypohidrosis remained a consideration. His forearm was notably anhidrotic by this assessment and revealed no sweat clinically, with absence of purple coloration on starch-iodine test. Punch biopsies of his axilla and forearm were performed; the axilla demonstrated moderately dense lichenoid lymphocytic infiltrate approximating the dermal-epidermal junction and extending into the lower epidermal layers. CD3 stains showed T-lymphocytes around hair follicles and blood vessels surrounding eccrine glands. CD4 and CD8 expression was approximately equal in the infiltrate. Similarly, forearm biopsy revealed a mild super