Anorexia, vomiting and weight loss in a 22-year-old woman

Clinical presentation

A 22-year-old woman presented in December 2017 with a 2-month history of postprandial abdominal pain, nausea, vomiting, early satiety and 4 kg weight loss. She had entirely normal bowel habit. She did not use non-steroidal anti-inflammatory drugs and omeprazole had not helped her symptoms. Her medical history included resection of 1.8 mm Spitz melanoma in June 2010 and left axillary dissection in November 2012 (3/22 nodes positive). She received first-line ipilimumab and nivolumab starting November 2016. Cycle 2 was complicated by grade 2 hepatotoxicity that resolved spontaneously; cycle 4 by grade 3 hepatotoxicity requiring steroids and mycophenolate mofetil (discontinued in August 2017). She had stereotactic radiosurgery for a right temporal lobe metastasis in June 2017 and restarted on maintenance nivolumab monotherapy in July 2017. In December 2017 her blood tests showed: normal haemoglobin; normal urea and electrolytes except potassium 3.4 mmol/L (normal range (NR) 3.5–5.0 mmol/L); and bilirubin 6 µmol/L, alanine transaminase 13...

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