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Rasi V, Riekhof F, Mahmoud M, Ejiofor S, Lentine KL. A Case of Hypernatremia in a Newly Diagnosed Patient With Acute Myeloid Leukemia: Lessons for Nephrologists. Cureus 2024; 16:e59186. [PMID: 38807832 PMCID: PMC11130080 DOI: 10.7759/cureus.59186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2024] [Indexed: 05/30/2024] Open
Abstract
Arginine vasopressin deficiency (AVP-D), formerly known as central diabetes insipidus, is a disease characterized by polyuria, polydipsia, and hypernatremia. The concomitant diagnosis of acute myeloid leukemia (AML) is an underappreciated event that requires prompt recognition and treatment by practicing nephrologists and hematologists. This report highlights this importance by describing the case of a 39-year-old patient newly diagnosed with AML who developed severe hypernatremia. The role of diagnostic testing through desmopressin (DDAVP) challenge and copeptin testing to confirm the diagnosis of AVP-D in this context and the use of DDVAP for treatment are discussed. Practicing nephrologists and primary care providers taking care of patients with similar symptoms will benefit from understanding the pathophysiology of AVP-D, its relationship with AML, and the prognosis in this patient cohort.
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Affiliation(s)
- Valerio Rasi
- Internal Medicine - Nephrology, Saint Louis University School of Medicine, Saint Louis, USA
- Internal Medicine, Baylor College of Medicine, Houston, USA
| | - Forest Riekhof
- Internal Medicine - Nephrology, Saint Louis University School of Medicine, Saint Louis, USA
| | - Maya Mahmoud
- Internal Medicine - Nephrology, Saint Louis University School of Medicine, Saint Louis, USA
| | - Shannon Ejiofor
- Internal Medicine - Nephrology, Saint Louis University School of Medicine, Saint Louis, USA
| | - Krista L Lentine
- Internal Medicine - Nephrology, Saint Louis University School of Medicine, Saint Louis, USA
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Arya R, Ahmad T, Dash S. Central diabetes insipidus and partial anterior pituitary dysfunction in acute myeloid leukemia. Endocrinol Diabetes Metab Case Rep 2022; 2022:21-0153. [PMID: 37931409 PMCID: PMC9346312 DOI: 10.1530/edm-21-0153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/27/2022] [Indexed: 11/18/2022] Open
Abstract
Summary Central diabetes insipidus (CDI) is a rare manifestation of acute myeloid leukemia (AML) with unclear etiology. When present, CDI in AML has most often been described in patients with chromosome 3 or 7 aberrations and no abnormalities on brain imaging. In this case, we present a woman with newly diagnosed AML t(12;14)(p12;q13) found to have diabetes insipidus (DI) with partial anterior pituitary dysfunction and abnormal brain imaging. While in hospital, the patient developed an elevated serum sodium of 151 mmol/L with a serum osmolality of 323 mmol/kg and urine osmolality of 154 mmol/kg. On history, she reported polyuria and polydipsia for 5 months preceding hospitalization. Based on her clinical symptoms and biochemistry, she was diagnosed with DI and treated using intravenous desmopressin with good effect; sodium improved to 144 mmol/L with a serum osmolality of 302 mmol/kg and urine osmolality of 501 mmol/kg. An MRI of the brain done for the assessment of neurologic involvement revealed symmetric high-T2 signal within the hypothalamus extending into the mamillary bodies bilaterally, a partially empty sella, and loss of the pituitary bright spot. A pituitary panel was completed which suggested partial anterior pituitary dysfunction. The patient's robust improvement with low-dose desmopressin therapy along with her imaging findings indicated a central rather than nephrogenic cause for her DI. Given the time course of her presentation with respect to her AML diagnosis, MRI findings, and investigations excluding other causes, her CDI and partial anterior pituitary dysfunction were suspected to be secondary to hypothalamic leukemic infiltration. Learning points Leukemic infiltration of the pituitary gland is a rare cause of central diabetes insipidus (CDI) in patients with acute myeloid leukemia (AML). Patients with AML and CDI may compensate for polyuria and prevent hypernatremia with increased water intake. AML-associated CDI can require long-term desmopressin treatment, independent of AML response to treatment.
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Affiliation(s)
- Rigya Arya
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tehmina Ahmad
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Satya Dash
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Banting and Best Diabetes Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Central Diabetes Insipidus Induced by Acute Myeloid Leukemia with DNMT3A Mutation. Case Rep Endocrinol 2022; 2022:2750146. [PMID: 35656122 PMCID: PMC9152344 DOI: 10.1155/2022/2750146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 05/03/2022] [Indexed: 11/17/2022] Open
Abstract
Central diabetes insipidus (CDI) is an uncommon complication of acute myeloid leukemia (AML). Patients present with polyuria either preceding or at the time of diagnosis of AML. We describe the case of a 36-year-old male who presented with a subacute onset of polyuria, polydipsia, nocturia, and fatigue. After an extensive workup, he was diagnosed with AML/CMML (chronic myelomonocytic leukemia) with a normal karyotype with DNMT3A, CBFB, and PTPN11 mutations. Further workup of the polyuria with a water deprivation test helped confirm the diagnosis of CDI along with MRI findings suggestive of hypophysitis. In this report, we analyze the clinical workup for AML and CDI and report the possibility of extramedullary leukemic infiltration associated with DNMT3A mutation, which has been reported as one of the mechanisms in the existing literature. We also discuss other theories hypothesized to cause CDI in AML patients with abnormal karyotypes. Our patient progressed to AML from CMML-2 after a cycle of decitabine, with confirmed gingival and presumed central nervous system (CNS) involvement. He is in minimal residual disease (MRD)-negative complete remission after induction with a CNS-active acute lymphoblastic leukemia-2 regimen. He also received double umbilical cord blood transplantation, conditioned with cyclophosphamide, fludarabine, thiotepa, and total body irradiation (TBI) of 4 Gy. This was complicated by engraftment syndrome for which he is currently being managed. CDI of the patient was corrected by desmopressin administration.
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Quessada J, Cuccuini W, Saultier P, Loosveld M, Harrison CJ, Lafage-Pochitaloff M. Cytogenetics of Pediatric Acute Myeloid Leukemia: A Review of the Current Knowledge. Genes (Basel) 2021; 12:924. [PMID: 34204358 PMCID: PMC8233729 DOI: 10.3390/genes12060924] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 01/04/2023] Open
Abstract
Pediatric acute myeloid leukemia is a rare and heterogeneous disease in relation to morphology, immunophenotyping, germline and somatic cytogenetic and genetic abnormalities. Over recent decades, outcomes have greatly improved, although survival rates remain around 70% and the relapse rate is high, at around 30%. Cytogenetics is an important factor for diagnosis and indication of prognosis. The main cytogenetic abnormalities are referenced in the current WHO classification of acute myeloid leukemia, where there is an indication for risk-adapted therapy. The aim of this article is to provide an updated review of cytogenetics in pediatric AML, describing well-known WHO entities, as well as new subgroups and germline mutations with therapeutic implications. We describe the main chromosomal abnormalities, their frequency according to age and AML subtypes, and their prognostic relevance within current therapeutic protocols. We focus on de novo AML and on cytogenetic diagnosis, including the practical difficulties encountered, based on the most recent hematological and cytogenetic recommendations.
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Affiliation(s)
- Julie Quessada
- Hematological Cytogenetics Laboratory, Timone Children’s Hospital, Assistance Publique-Hôpitaux de Marseille (APHM), Faculté de Médecine, Aix Marseille University, 13005 Marseille, France;
- Aix Marseille University, CNRS, INSERM, CIML, 13009 Marseille, France;
| | - Wendy Cuccuini
- Hematological Cytogenetics Laboratory, Saint-Louis Hospital, Assistance Publique des Hôpitaux de Paris (APHP), 75010 Paris, France;
- Groupe Francophone de Cytogénétique Hématologique (GFCH), 1 Avenue Claude Vellefaux, 75475 Paris, France
| | - Paul Saultier
- APHM, La Timone Children’s Hospital Department of Pediatric Hematology and Oncology, 13005 Marseille, France;
- Faculté de Médecine, Aix Marseille University, INSERM, INRAe, C2VN, 13005 Marseille, France
| | - Marie Loosveld
- Aix Marseille University, CNRS, INSERM, CIML, 13009 Marseille, France;
- Hematology Laboratory, Timone Hospital, Assistance Publique-Hôpitaux de Marseille (APHM), 13005 Marseille, France
| | - Christine J. Harrison
- Leukaemia Research Cytogenetics Group Translational and Clinical Research Institute, Newcastle University Centre for Cancer Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE1 7RU, UK;
| | - Marina Lafage-Pochitaloff
- Hematological Cytogenetics Laboratory, Timone Children’s Hospital, Assistance Publique-Hôpitaux de Marseille (APHM), Faculté de Médecine, Aix Marseille University, 13005 Marseille, France;
- Groupe Francophone de Cytogénétique Hématologique (GFCH), 1 Avenue Claude Vellefaux, 75475 Paris, France
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Lê HH, Lengelé JP, Henin M, Toffoli S, Mineur P. Diabetes insipidus and acute myeloid leukemia harboring monosomy 7: report of two cases and literature review. Acta Clin Belg 2021; 76:132-135. [PMID: 31452466 DOI: 10.1080/17843286.2019.1660024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Acute myeloid leukemia (AML) is unusually associated with diabetes insipidus (DI) in patients bearing monosomy 7 or chromosome 3 aberrations. To date, 84 cases have been reported worldwide. Physiopathological mechanisms linking these chromosomal abnormalities to DI are not yet understood. We report two patients with AML/DI and review the medical literature on those conditions.
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Affiliation(s)
- Huu Hanh Lê
- Medical School, University of Liège, Liège, Belgium
- Department of Nephrology, Grand Hôpital de Charleroi, Gilly, Belgium
- Department of Hematology, Grand Hôpital de Charleroi, Gilly, Belgium
| | | | - Marie Henin
- Department of Radiology, Grand Hôpital de Charleroi, Gilly, Belgium
| | - Sébastien Toffoli
- Centre for Human Genetics, Institute of Pathology and Genetics, Gosselies, Belgium
| | - Philippe Mineur
- Department of Hematology, Grand Hôpital de Charleroi, Gilly, Belgium
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Molina JC, Asare JM, Tuschong L, West RR, Calvo KR, Persky R, Boyce AM, Hammoud DA, Holland SM, Hickstein D, Shah NN. Venetoclax/decitabine for a pediatric patient with chronic myelomonocytic leukemia. Pediatr Blood Cancer 2021; 68:e28865. [PMID: 33369023 PMCID: PMC9357463 DOI: 10.1002/pbc.28865] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/07/2020] [Accepted: 12/10/2020] [Indexed: 12/23/2022]
Abstract
Chronic myelomonocytic leukemia (CMML) is a myelodysplastic syndrome (MDS)/myeloproliferative disorder most commonly seen in the elderly. We describe an adolescent with monosomy 7 CMML presenting as central diabetes insipidus (DI), who was treated with venetoclax and decitabine as a bridge to hematopoietic stem cell transplantation (HSCT). Central DI is a rare manifestation of monosomy 7-associated MDS including CMML, itself a rare manifestation of GATA2 deficiency, particularly in children. Venetoclax/decitabine was effective for treatment of CMML as a bridge to HSCT.
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Affiliation(s)
- John C. Molina
- Pediatric Oncology Branch, Center for Cancer Research (CCR)National Cancer Institute (NCI)NIH, Bethesda, Maryland,Department of Pediatric Oncology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Julie M. Asare
- Department of Pediatric Oncology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Laura Tuschong
- Immune Deficiency-Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Robert R. West
- Immune Deficiency-Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Katherine R. Calvo
- Department of Laboratory Medicine, NIH Clinical Center, Bethesda, Maryland
| | - Rebecca Persky
- National Institute of Child Health and Human Development, NIH, Bethesda, Maryland,Department of Pediatric Endocrinology, Children’s National Medical Center, Washington, District of Columbia
| | - Alison M. Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial ResearchNIH, Bethesda, Maryland
| | - Dima A. Hammoud
- Center for Infectious Disease Imaging (CIDI), Radiology and Imaging Sciences, NIH Clinical Center, Bethesda, Maryland
| | - Steven M. Holland
- Immunopathogenesis Section, National Institute of Allergy and Infectious DiseasesNIH, Bethesda, Maryland
| | - Dennis Hickstein
- Immune Deficiency-Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Nirali N. Shah
- Pediatric Oncology Branch, Center for Cancer Research (CCR)National Cancer Institute (NCI)NIH, Bethesda, Maryland
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Pritzl SL, Matson DR, Juckett MB, Ciske DJ. Concurrent Central Diabetes Insipidus and Acute Myeloid Leukemia. Case Rep Hematol 2021; 2021:8898671. [PMID: 33643671 PMCID: PMC7902136 DOI: 10.1155/2021/8898671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 02/02/2021] [Accepted: 02/08/2021] [Indexed: 11/19/2022] Open
Abstract
Central diabetes insipidus (CDI) is a rare reported complication of acute myeloid leukemia (AML). The onset of AML-associated CDI often precedes the diagnosis of AML by weeks or months and is considered an adverse prognostic indicator in this setting. The mechanism of AML-associated CDI is not known; however, it is often reported in the setting of cytogenetic events resulting in MDS1 and EVI1 complex locus protein (MECOM) gene overexpression. Here, we describe a case of new onset CDI which preceded a diagnosis of AML by 1 month. We detail the clinical and laboratory evaluation of the patient's CDI, and we describe the pathological and laboratory workup of their AML, which ultimately yielded a diagnosis of AML with myelodysplasia-related changes. Additional cytogenetic findings included the identification of the t (2;3)(p23;q27), which leads to MECOM gene overexpression and which to our knowledge has not previously been reported in the setting of AML-associated CDI. The patient received induction chemotherapy followed by allogeneic hematopoietic stem cell transplantation but experienced disease relapse and passed away nine months after initial diagnosis. We emphasize that new onset CDI can occur as a rare complication of AML where it portends a poor prognosis and may be related to AML subtypes displaying MECOM gene dysregulation.
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Affiliation(s)
- Stephanie L. Pritzl
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Daniel R. Matson
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Mark B. Juckett
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - David J. Ciske
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Farrell TP, Adams NC, Looby S. Neuroimaging of central diabetes insipidus. HANDBOOK OF CLINICAL NEUROLOGY 2021; 181:207-237. [PMID: 34238459 DOI: 10.1016/b978-0-12-820683-6.00016-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Central diabetes insipidus (CDI) occurs secondary to deficient synthesis or secretion of arginine vasopressin peptide from the hypothalamo-neurohypophyseal system (HNS). It is characterized by polydipsia and polyuria (urine output >30mL/kg/day in adults and >2l/m2/24h in children) of dilute urine (<250mOsm/L). It can result from any pathology affecting one or more components of the HNS including the hypothalamic osmoreceptors, supraoptic or paraventricular nuclei, and median eminence of the hypothalamus, infundibulum, stalk or the posterior pituitary gland. MRI is the imaging modality of choice for evaluation of the hypothalamic-pituitary axis (HPA), and a dedicated pituitary or sella protocol is essential. CT can provide complimentary diagnostic information and is also of value when MRI is contraindicated. The most common causes are benign or malignant neoplasia of the HPA (25%), surgery (20%), and head trauma (16%). No cause is identified in up to 30% of cases, classified as idiopathic CDI. Knowledge of the anatomy and physiology of the HNS is crucial when evaluating a patient with CDI. Establishing the etiology of CDI with MRI in combination with clinical and biochemical assessment facilitates appropriate targeted treatment. This chapter illustrates the wide variety of causes and imaging correlates of CDI on neuroimaging, discusses the optimal imaging protocols, and revises the detailed neuroanatomy required to interpret these studies.
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Affiliation(s)
- Terence Patrick Farrell
- Division of Neuroradiology, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Niamh Catherine Adams
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Seamus Looby
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
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