Case report of a thermal burns patient with diabetes insipidus

We report a rare case of diabetes insipidus following fire burn injury. Meticulous fluid balance and the use of carbamazepine resulted in her survival.

A case of central diabetes insipidus following probable type A/H1N1 influenza infection

The major causes of central diabetes insipidus (CDI) are neoplastic or infiltrative lesions of the hypothalamus or pituitary gland, severe head injuries, or pituitary or hypothalamic surgery. Lymphocytic infundibuloneurophysitis (LINH) is associated with autoimmune inflammatory disease of the pituitary gland, but the exact etiology is unknown. CDI caused by viral infections has been rarely reported. Here, we describe the case of a 22-year-old man who was in good health until 2 months prior to admission, presented with acute development of polyuria and polydipsia, and showed increased urinary volume up to 9000 mL/day. The patient showed elevated serum osmolality and low urine osmolality, with a low level of antidiuretic hormone. Endocrinological findings revealed CDI, but his arterial pituitary function appeared normal. Magnetic resonance imaging revealed significant enlargement of the pituitary stalk. We suspected CDI due to LINH based on non-transsphenoidal biopsy findings. He was diagnosed as type A influenza,and given oral therapeutic agents. However, acute onset of polyuria and polydipsia occurred 10 days after the influenza diagnosis. The available epidemiological information regarding the outbreak of influenza around that time strongly suggested that the patient was infected with the A/H1N1 influenza virus, although this virus had not been detected on polymerase chain reaction testing. In the present case, the autoimmune mechanism of LINH may have been associated with novel influenza A/H1N1 virus infection.

[Case of mixed connective tissue disease complicated with sarcoidosis and central diabetes insipidus]

In 2003, a 64-year-old woman was diagnosed with mixed connective tissue disease and treated with oral prednisolone (30 mg/day). The prednisolone dose was gradually decreased, and a dose of 5 mg/day had been maintained since 2004. In 2009, she gradually developed vision loss, malaise, anorexia, and throat pain due to hydrodipsia. She was noted to have iritis and vitreous opacity by an ophthalmologist, and was referred for further evaluation. Fine rales were audible throughout the entire lung field, and chest CT showed diffuse small nodules that were more prominent on the upper and middle lobes, and swelling of the mediastinal and hilar lymph nodes. Transbronchial lung biopsy showed many epithelioid granulomas with multinuclear giant cells, compatible with sarcoidosis. Polyuria was identified as a cause of hydrodipsia and a diagnosis of partial central diabetes insipidus was made. High-dose prednisolone (40 mg/day) together with intranasal administration of desmopressin resulted in improvement of all of her clinical symptoms. MCTD followed by sarcoidosis is rare. Furthermore, this is the first reported case of MCTD complicated by sarcoidosis and central diabetes insipidus.

Lymphocytic infundibuloneurohypophysitis: long-term follow-up of a case cured with glucocorticoid

OBJECTIVE

To report a case of infundibuloneurohypophysitis treated with steroid.

CLINICAL PRESENTATION

A 65-year-old woman who was well until 4 weeks before admission and was not taking any medication presented with acute development of polydipsia and polyuria. Urinary volume was increased to 4,500 ml/day. She showed elevated serum osmolality and low urine osmolality, together with shortage of antidiuretic hormone. Magnetic resonance imaging (MRI) of the pituitary revealed marked nodular thickening of the neurohypophysis. Endocrinologically, anterior pituitary function appeared normal. Based on these examinations, she was diagnosed as having central diabetes insipidus due to lymphocytic infundibuloneurohypophysitis.

INTERVENTION

Prednisolone (1 mg/kg/day, p.o.) and D-deaminovasopressin (5 microg/day, intranasal) were commenced. Ten days after the administration of the agents, MRI showed a dramatic improvement in the thickening of the neurohypophysis. Ten weeks later, abnormalities found in earlier MRI had disappeared. The drugs were withdrawn gradually, and diabetes insipidus ceased 25 weeks later. Recurrence was not seen in the subsequent MRI, and the function of the posterior pituitary gland was completely normalized even 7 years after discontinuation of treatments.

CONCLUSION

This case shows that noninvasive diagnosis and appropriate steroid administration can effectively cure lymphocytic infundibuloneurohypophysitis; it is recommended with long-term follow-up.

A patient with essential hypernatremia had good response to desmopressin acetate therapy

OBJECTIVES

Essential hypernatremia is very rare in clinical practice and the pathogenesis is unclear. We performed a set of clinical tests to a patient with chronic and sustained hypernatremia as well as absence of thirst in order to investigate the clinical characteristics and make the diagnosis, yet most importantly to analyze the possible pathogenesis and explore a possible therapy regime.

METHODS

Water deprivation test and acute water intravenous loading test were performed to observe the changes of urinary osmolality, plasma osmolality and plasma sodium. Free water clearance (C(H₂O) was calculated. Osmolality was detected using the method of freezing point depression, and thirst grade using visual analogue scales. Desmopressin acetate (0.05-0.1 mg/d) was administered to the patient in order to observe the therapeutic effects to his disorder.

RESULTS

The patient had sustained hypernatremia over a long period of time, decreased thirst, normal renal function, as well as absence of clinical hypovoluemia. The plasma sodium was 160-190 mmol/L and plasma osmolality was 330-370 mOsm/L without any thirst perception which could not be corrected by water intake. An 18-hour period of water deprivation increased the urinary osmolality from 368 mOsm/L to 420 mOsm/L with plasma osmolality increasing from 362 mOsm/L to 369 mOsm/L and rising further to 857 mOsm/L after an injection of 5 u vasopresin. With the infusion of 1 250 ml 5%-glucose during 2 hours in an acute water loading test setting, plasma osmolality decreased from 350 mOsm/L to 334 mOsm/L associated with a plasma sodium decrease from 164.7 mmol/L to 155 mmol/L urinary osmolality dropped from a maximum of 632 mOsm/L to 135 mOsm/L urinary volume from 0.25 ml/min to 2.33 ml/min and C(H₂O) from -0.18 ml/min to 1.19 ml/min after acute water loading with 1 250 ml glucose dissolved in water. Our results reveal that treatment of the patient with Desmopressin acetate relieved the adypsia, hypernatremia and hyperosmolality effectively.

CONCLUSIONS

The patient was considered as suffering from essential hypernatremia which was associated with partial central diabetes insipidus and adypsia. Desmopressin acetate as a common therapeutic agent of central diabetes insipidus proved to be an effective treatment for essential hypernatremia.

Transient polyuria related to central diabetes insipidus caused by lymphocytic infundibulo-neurohypophysitis in a patient treated for Graves' disease

A 45-year-old man was hospitalized because of weight loss, finger tremor, thirst, polydipsia and increased urinary frequency. He was diagnosed with Graves' disease (GD) and central diabetes insipidus (CDI). Magnetic resonance imaging revealed the enlarged posterior pituitary with thickened stalk. Histological examination obtained from biopsy of the pituitary revealed lymphocytic infundibulo-neurohypophysitis. He received treatment with thiamazole (MMI) for GD and desmopressin acetate (DDAVP) for CDI. However, DDAVP administration could be discontinued as GD was gradually improved. This course indicates that not only the recovered renal response to arginine-vasopressin but also the immunomodulative effects of MMI might attribute to the improvement of polyuria.

[Osmoregulating effect of vasopressin with prolonged action on Brattleboro rats with hypothalamic diabetes insipidus]

The particularities of urine osmotic concentration depending on hormonal background of vasopressin were studied in rats. It was found that WAG and Brattleboro lines of rats characterized respectively by normal level and absence of endogenous vasopressin, possess interline correlation of urine osmolality (p = 0.86) in various conditions between the extreme hydrating and dehydratation. Concentrating level of WAG rats varies from 747 +/- 94 to 2936 +/- 128 mOsm/kg, but that of Brattleboro rats changes more within the 160 +/- 9 being twice lower as isotonicity to 1305 +/- 142 mOcm/kg. Urine concentrating goes up to 1391 +/- 76 mOcm/kg in Brattleboro rats already on the day of the action of exogenous vasopressin secreted from ALZET minipump, however, in spite of constant work of this minipump during 4 hrs a week, further increasing of urine osmolality was not observed in Brattleboro rats.

Wegener's granulomatosis complicated by central diabetes insipidus and peripheral neutrophy with normal pituitary in a patient

Wegener's granulomatosis (WG) is a necrotizing systemic vasculitis that any organ system can be involved in. We report a patient who was hospitalized with recurrent nodules in pulmonary computed tomograph and symptoms such as intermitted fever, polydipsia, insensibility and pain on extremities. Laboratory investigation showed positive antineutrophil cytoplasmic antibody in a cytoplastic pattern. The histopathologic result of the lung nodule revealed multiloci necrosis of lung tissue accompanied with large amount of neutrophils. She was diagnosed as WG with multi-systemic involvements and almost recovered on 6 months' prednisone and cyclophosphamide treatment.

Management of central diabetes insipidus with oral desmopressin in a patient with ectrodactyly and cleft lip/palate (ECP) syndrome

We present a female infant with facial abnormalities such as bilateral cleft lip and palate, ectrodactyly and central diabetes insipidus. She had a history of recurrent hypernatremic attacks and she was treated successfully with oral desmopressin. As an alternative to the nasal route, long-term management was achieved using oral route and she had a favorable growth and development during infancy.

[Incomplete central diabetes insipidus in living kidney transplant patient]

A 31-year-old man was sent to hospital for urgent treatment. He was in the terminal state of chronic renal failure, and was placed under hemodialysis immediately. Proteinuria and hypertension had been notified since adolescence, had been left untreated, and there was no record of his conditions, was. Living kidney transplantation was conducted 8 months later. The donor was his father. After the operation, rejection was not recognized, but urine volume per day was not reduced and maintained the level around 10.000 ml. At the same time, the decrease of body weight and the rise in the serum creatinine concentration were noted. The results of magnetic resonance imaging and the hypertonic saline test (Hickey Hare Test) have formed diagnosis of incomplete diabetes insipidus. Immediately after the administration of desmopressin (rhinenchysis), the decrease of urine volume was recognized, and the body weight and serum creatinine concentration became stable.

Desmopressin increases IGF-binding protein-1 in humans

CONTEXT

IGF binding protein-1 (IGFBP-1) is essential for IGF-I bioavailability. High levels of IGFBP-1 are encountered in critically ill patients and are a good predictor marker in acute myocardial infarction. The mechanisms responsible for the elevated IGFBP-1 levels in these conditions are still unclear. Interestingly, high levels of vasopressin have been reported in the above-mentioned conditions.

OBJECTIVE

To study the effect of vasopressin on IGFBP-1 in humans.

DESIGN

Placebo-controlled cross-over study in patients with central diabetes insipidus (CDI) in whom potential interference from endogenous vasopressin secretion is minimized. After a 3-day desmopressin washout period, each patient received i.v. saline on day 1 and desmopressin (3 mug) on day 2. Blood samples were taken after administration, every 2 h during the whole night, starting at 2000 h.

PATIENTS AND SETTING

Fourteen inpatients with CDI in an endocrinology department of a university hospital.

RESULTS

Serum IGFBP-1 increased within 4 h after 1-desamino-8-d-arginine vasopressin (DDAVP) by 375+/-73%, compared with a spontaneous fasting increase by 252+/-46% following placebo administration (P<0.05). No changes were registered in the levels of either classically regulators of IGFBP-1 (insulin, glucagon, and cortisol) or of IGF-I and glucose. The decrease in plasma osmolarity induced by DDAVP did not precede the increase in IGFBP-1.

CONCLUSIONS

DDAVP increases serum levels of IGFBP-1. Further investigation is essential to unravel the clinical potential of this interaction in conditions associated with high IGFBP-1 levels.

Pituitary involvement in Wegener's granulomatosis

Wegener's granulomatosis (WG) is an anti-neutrophil cytoplasmic antibody (ANCA)-associated systemic vasculitis of small and medium-sized vessels. Pituitary involvement in WG is rare with only 22 previous case reports in the English medical literature between 1966 and 2006. Herein we report another patient with WG-related diabetes insipidus (DI) and partial disruption of the anterior pituitary axes. We also review the clinical features, imaging findings, treatment and outcome of WG-related pituitary involvement. Isolated pituitary involvement in the absence of lung or renal complications in WG is rare and described in only one previous patient. Pituitary involvement in WG is usually associated with other organ involvement (96% of cases)-commonly upper respiratory tract (93%), lungs (73%) and kidneys (67%). Abnormalities are often seen in the hypothalamo-pituitary region on magnetic resonance imaging (MRI) or computed tomography (CT) of the head (90% of cases). In 65% of reported cases, cyclophosphamide-based induction therapy was used with a subsequent relapse rate of 27%, occurring at a median of 10.5 months (range: 7-36 months) after initiation of treatment. In comparison, induction treatment without cyclophosphamide was associated with relapse in 50% at a median of 4.5 months (range: 4-18 months after starting treatment) suggesting more frequent and earlier relapse. Therefore, we recommend treatment with cyclophosphamide-based regimen. Despite treatment of WG, only 17% (4 patients) had full recovery in their pituitary function. The long-term prognosis of patients with WG and pituitary involvement is not known.

Pituitary abscess: our experience with a case and a review of the literature

Pituitary abscess is a rare disease. Due to its potentially high mortality and morbidity rate, it should be considered in the differential diagnosis of sellar masses. Despite recent advances in radiological investigations, making a definitive diagnosis preoperatively remains challenging. This 45-year-old Indian gentleman presented with severe throbbing headache for six months. Magnetic resonance imaging of the brain revealed a sellar mass with peripheral enhancement that was misdiagnosed as a pituitary macroadenoma. A trans-sphenoidal excision was done, which surprisingly yielded only pus that was drained accordingly from the lesion. Fungal and bacterial cultures were negative. However this patient subsequently lost complete function of the pituitary gland, resulting in central diabetes insipidus and required permanent hormonal replacement therapy in the deficient endocrine axes. A Medline search was conducted and a review of 24 cases reported in the last 5 years discussed.

[Case of neurosarcoidosis with rapid visual field defect progression]

OBJECTIVE

To report a case of neurosarcoidosis with rapid progression of visual field defects.

CASE

A 28-year-old woman presented with bilateral uveitis and was diagnosed as having sarcoidosis after skin and cervical lymph node biopsy. Since bilateral excavations of the optic nerve head and visual field defects were observed, endocranial lesion was suspected. However, a computed tomography (CT) scan of the head detected nothing abnormal. It was regarded as a case of sarcoidosisaccompanied by normal-tension glaucoma and treatment was initiated with latanoprost. Four months later, the patient's visual field deteriorated rapidly. A CT scan showed a pituitary mass. Neurologicalfindings and hypopituitarism were found which improved with systemic prednisolone therapy. Diabetes insipidus developed after the start of treatment, and was treated with intranasal desmopressin therapy. After 6 weeks, head magnetic resonance imaging (MRI) showed a remarkable reduction of the enhanced regions.

CONCLUSIONS

Although ocular sarcoidosis is often accompanied by secondary glaucoma or optic nerve atrophy, the progression of neurosarcoidosis can lead to visual field defects. Central nervous system (CNS) sarcoidosis is rare, but a precise examination with enhanced MRI should be considered when the visual field defect progresses rapidly.

An elderly patient with sarcoidosis manifesting panhypopituitarism with central diabetes insipidus

We here report a 77-year-old Japanese male who suffered general fatigue with progressive thirst and polyuria. Central diabetes insipidus was diagnosed by depletion of vasopressin secretion in response to increases in serum osmolality. Secretory responses of anterior pituitary hormones including adrenocorticotropin, thyrotropin, gonadotropins and growth hormone were severely impaired. Diffuse swelling of the infundibulum as well as lack of T1-hyperintense signal in the posterior lobe was noted by pituitary magnetic resonance imaging. The presence of bilateral hilar lymphadenopathy and increased CD4/CD8 ratio in bronchoalveolar lavage fluid was diagnostic for lung sarcoidosis. Physiological doses of corticosteroid and thyroid hormone were administered in addition to desmopressin supplementation. Complete regression of the neurohypophysial swelling was notable two years after corticosteroid replacement. Diffuse damage of anterior pituitary combined with hypothalamic involvement leading to central diabetes insipidus is a rare manifestation in such elderly patients with neurosarcoidosis.

The management of central diabetes insipidus in infancy: desmopressin, low renal solute load formula, thiazide diuretics

Infants consume most of their calories as formula. Because of this large fluid intake, infants normally produce dilute urine, not far off from that seen in individuals with diabetes insipidus (DI). Infants with DI are therefore prone to water intoxication if fixed antidiuresis is achieved using the long-acting vasopressin analog desmopressin (DDAVP), which induces a state of high urine concentration. DI treatment approaches applied to older children and adults, who consume the their calories as solids, are difficult to apply to infants with DI. When used in infants, oral and intranasal DDAVP can be associated with wide swings in serum sodium concentration (SNA). In comparison, precisely administered subcutaneous doses of DDAVP can be successfully used in infants with DI, and appear to be superior to oral or intranasal DDAVP therapy. Alternatively, consistent eunatremia can be simply achieved in infantile DI using low renal solute load (RSL) formula and thiazide diuretics. Low RSL formula reduces obligatory urinary water losses, and thiazide diuretics concentrate the urine to levels seen in normal formula-fed infants. This report addresses treatment options of DI in infancy and the delicate management issues involved.

[A case of sarcoidosis with diabetes insipidus]

A 15-year-old girl was admitted to our hospital because of polydipsia, polyuria, bilateral hilar lymphadenopathy and uveitis. A diagnosis of sarcoidosis with central diabetes insipidus was made by radiological, serological, bronchoalveolar lavage examinations, fluid restriction test and vasopression test. Prednisolone therapy improved all of her clinical findings except diabetes insipidus. So she had to continue intranasal 1-desamino-8-arginine vasopressin (DDAVP) therapy. In addition, we reviewed the clinical features of 27 patients of sarcoidosis with diabetes insipidus reported in Japan. They included 12 patients in young men and 21 patients having uveitis. These patients showed low frequency of lung complications in comparison with sarcoidosis without diabetes insipidus. Steroid therapy improved the symptoms of diabetes insipidus in only 3 patients, and all these 3 patients started steroid therapy within 1 month after the onset. Therefore we think that early diagnosis and treatment are important. Though central neurosarcoidosis was generally considered to have poor prognosis, there were only 3 patients who had recurrence by steroid tapering.

Use of subcutaneous DDAVP in infants with central diabetes insipidus

Traditional methods for treating central diabetes insipidus during infancy, such as fluid therapy or the use of intranasal hormone replacement, have significant potential limitations. In a retrospective study of infants with diabetes insipidus, we examined outcome using subcutaneous (sc) DDAVP, and compared this to infants treated with intranasal lysine vasopressin or DDAVP. After in-patient dosage titration, outpatients' serum sodium concentrations were maintained in a narrower range in the sc group compared with the intranasal group, and the percentage of serum sodium concentrations within the normal range was greater in the sc group. There were no significant complications in either group. We conclude that DDAVP administered subcutaneously can be a safe and effective alternative to traditionally recommended treatments of central diabetes insipidus during infancy.

Trauma-induced central diabetes insipidus in a cat

A 1-year-old neutered male domestic shorthair cat presented with a 4-week history of polydipsia that began immediately after an 8 metre fall. Trauma-induced central diabetes insipidus was suspected on the basis of the identification of hyposthenuria, normal haematology and serum biochemistry profile and unremarkable abdominal ultrasound examination. Failure to concentrate urine with water deprivation followed by production of hypersthenuric urine with administration of the synthetic antidiuretic hormone, Deamino-8-D-arginine vasopressin (DDAVP), confirmed the diagnosis of central diabetes insipidus. Treatment via conjunctival administration of DDAVP failed to attenuate the polydipsia, however, resolution of polydipsia was achieved with subcutaneous administration of DDAVP and the cat remains eudipsic with twice daily subcutaneous DDAVP administration 17 months after diagnosis.

[Cranial diabetes insipidus in Wegener's granulomatosis]

We describe three cases of cranial diabetes insipidus (CDI) caused by Wegener's granulomatosis (WG). Panhypopituitarism was the presenting symptom in one patient. Magnetic resonance imaging (MRI) showed enlargement of the pituitary gland with an intrasellar mass lesion and absence of posterior pituitary lobe hyperintensity. Follow-up MRI disclosed reduction of the intrasellar lesion but sustained loss of posterior lobe hyperintensity. The patients still have CDI despite a marked clinical response to the treatment of WG. Pituitary dysfunction may be the presenting symptom as well as a complication of WG.

Diabetes insipidus: diagnosis and treatment of a complex disease

Diabetes insipidus, characterized by excretion of copious volumes of dilute urine, can be life-threatening if not properly diagnosed and managed. It can be caused by two fundamentally different defects: inadequate or impaired secretion of antidiuretic hormone (ADH) from the posterior pituitary gland (neurogenic or central diabetes insipidus) or impaired or insufficient renal response to ADH (nephrogenic diabetes insipidus). The distinction is essential for effective treatment.