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, Non"faite" Hydrocortisone"30"mg/j
, !"pas"de"récupération"à"2"ans" Normale" Hydrocortisone"20"mg/j" Levothyrox®"150"µg/j" "! Thyroïdectomie" Stabilité"8"mois" Suivi"total"36"mois" Patient"8" Asymptomatique" 2" Insuffisance"corticotrope," thyréotrope,"gonadotrope"et" somatotrope"" !"récupération"complète"à"6"mois, Normale" Hydrocortisone"30"mg/j" Levothyrox®"100"µg/j" Pas"de"réponse" Suivi"total"23"mois" Patient"7" AEG" Céphalée" 3" Insuffisance"corticotrope
#La#glycémie#était#à#6,39#g/L#avec# une# croix# de# cétone# dans# les# urines.# Les# anticorps# anti?GAD# et# IA2# étaient# négatifs# et# les# anticorps# anti?insuline# se# sont# positivés# à# 1,8%# (négatif# si# inférieur# à# 0,4%).# Le# scanner# pancréatique#était#normal.#Un#traitement#par#insuline#a#été#instauré#(84).## # Notre#patiente#est#donc#le#troisième#cas#décrit#de#diabète#induit#par#anticorps#anti?CTLA?4.# Contrairement#aux#deux#cas#précédents,#elle#n'avait#pas#été#traitée#par#anticorps#anti?PD1#au# préalable.#Elle#a#présenté#un#tableau#d'acidocétose#un#mois#après#le#début#de#l'ipilimumab#et# avait#des#anticorps#anti?GAD#très#fortement#positifs#à#23933#U/ml#associés#à#des#anticorps# anti?insuline#faiblement#positifs.#L'HbA1c#et#le#C?peptide#initiaux#n'étaient#pas#disponibles.#La# lipasémie#initiale#était#très#élevée.## # L'histoire# clinico?biologique# de# ces# diabètes# s'apparente# à# celle# des# diabètes# fulminants# décrite# dans# les# pays# d'Asie.# En# effet,# les# patients# présentent# des# tableaux# brutaux# d'acidocétose# avec# des# HbA1c# modérément# élevées# témoignant# de# l'installation# rapide# du# diabète.#Les#auto?anticorps#sont#positifs#chez#la#moitié#des#patients,#le#C?peptide#effondré#et# la#lipasémie#initialement#élevée.## Le# délai# de# survenue# des# diabètes# induits# par# ICPi# varie# de# 3# semaines# à# 12# mois# après# l'instauration#de#l'ICPi.#Il#s'installerait#plus#rapidement#en#présence#d'auto?anticorps#(96), Testostérone"Totale"(TestoT)":"1,44b6,92"ng/mL" IgF1"51b60"ans":"99b254"ng/mL ,
, ## # En#tous#les#cas,#la#survenue#d'un#diabète#induit#par#un#ICPi#est#très#rare.#Il#faut#savoir#y#penser# devant#la#gravité#du#tableau#initial#d'acidocétose.## Il#semblerait#que#ce#diabète#soit#définitif#puisque#tous#les#patients#décrits#dans#la#littérature# ont#ensuite#été#traités#par#insuline#au#long#cours.#Une#fois#l'insulinothérapie#mise#en#place,#la# poursuite#de#l'ICPi#n'est#pas#contre?indiquée.#### Il#est#difficile#d'établir#un#arbre#décisionnel#devant#le#peu#de#cas#décrits, L'implication#de#CTLA?4#dans#la#survenue#d'un#diabète#de#type#1#est#moins#étudiée.# Il#a#cependant#été#mis#en#évidence#que#le#polymorphisme#dans#la#région#du#gène#codant#pour# CTLA?4#est#associé#à#un#surrisque#de#diabète#de#type#1#chez#certains#individus#(101)