Chronic hypernatremia from a congenital defect in osmoregulation of thirst and vasopressin

When Thirst Ceases to Exist: A Case Report and Literature Review of Adipsic Diabetes Insipidus Following Coil Embolization of a Ruptured Anterior Communicating Artery Aneurysm

Diabetes insipidus is a condition characterized by inappropriately dilute urine in the setting of serum hyperosmolality. The two predominant subtypes include central (from lack of vasopressin production) and nephrogenic diabetes insipidus (from renal resistance to circulating vasopressin). A common manifestation is the significant pursuant thirst from excessive polyuria. We present a case report and literature review of an infrequent variation of central diabetes insipidus known as adipsic (hypothalamic) diabetes insipidus, characterized by the absence of thirst, secondary to coiling of a ruptured anterior communicating artery aneurysm. Due to the loss of thirst, patients are at a heightened risk for hypernatremia and complications secondary to dehydration. Our patient's course was complicated by recurrent polyuria and hypernatremia, requiring a fixed-dose desmopressin regimen. On follow-up, only partial thirst sensation was restored. We provide a literature review to compare our case report to the scant literature available to broaden the awareness of this infrequent, perilous, manifestation.

Microalgae-Based Disinfectant Formulation for Aseptic Processing of Ethiopian Ingredient-Sourced Functional Bread and Its Molecular Docking Analysis to Reduce Hypernatremia

The global prevalence of food-borne infections has become a major concern. Food-borne pathogens like Campylobacter jejuni, Salmonella enterica, and Clostridium botulinum cause food poisoning and even mortality, necessitating the maintenance of aseptic conditions during food processing. The sterilization of food processing facilities often requires chemical and heat treatment. The formulation of many chemical-based disinfectants includes chemicals generating toxic and carcinogenic by-products. The microalgae like Chlorella spp. reportedly exhibit antimicrobial activity and therefore, can be used for formulating safer and eco-friendly natural sanitizers. This study aims to aseptically prepare functional bread using Ethiopian ingredients, highlighting the application of microalgae-based disinfectant formulation and various disinfection techniques. The functional bread was designed to be potentially effective in reducing hypernatremia condition which is indicative of high levels of sodium in serum that can cause an array of symptoms including deaths in serious cases. The physico-chemical and sensory properties of the designed functional bread were analyzed. The interaction of phytochemicals in the ingredients with the target receptor (Vasopressin V2 receptor) and their drug-likeness were determined using molecular docking and Lipinski's rule of five analyses. The results suggest that the designed functional bread incorporating Ethiopian ingredients may serve as an effective dietary strategy to prevent hypernatremia. Aseptic processing of the bread ensures longer shelf life and prevention of spoilage by food pathogens.

Successful treatment of hypodipsic/adipsic hypernatremia in a cat with lobar holoprosencephaly using oral desmopressin

Case summary

A 2-year-old female spayed domestic shorthair cat was presented with a history of collapse, possible hypodipsia/adipsia, severe dehydration and hypernatremia. MRI of the brain revealed a failure of separation of the cerebral hemispheres as characterized by an absence of the rostral part of the corpus callosum, fornix and septum pellucidum and the presence of a single fused lateral ventricle. A diagnosis of hypodipsic/adipsic hypernatremia with lobar holoprosencephaly was made. Dietary management of the cat's condition was attempted by increasing oral water intake, but the cat's hypernatremia and azotemia persisted. Plasma arginine vasopressin (AVP) analysis revealed a low concentration of circulating AVP (2.3 pg/ml), prompting therapy with oral desmopressin in addition to the dietary management. This combined therapy decreased water consumption of the cat from 200 ml/day (85 ml/kg/day) to 100 ml/day (30 ml/kg/day), normalized plasma sodium concentration and resolved the azotemia.

Relevance and novel information

To our knowledge, this is the second case report of an MRI diagnosis of lobar holoprosencephaly with hypodipsic/adipsic hypernatremia in a cat and the first case report of the successful management of this condition using oral desmopressin. This case report emphasizes that holoprosencephaly should be suspected in cats presented with hypodipsic/adipsic hypernatremia and highlights the utility of MRI in establishing the diagnosis. Measurements of plasma osmolality and AVP concentration corroborate the pathophysiology and support the use of oral desmopressin in addition to dietary management to resolve the hypernatremia.

Congenital pituitary cyst resulting in adipsic central diabetes insipidus and secondary hypernatremia in a cat

Case summary

A 9-month-old intact female domestic mediumhair cat presented with a 5-month history of obtundation, lethargy, hypernatremia (181 mmol/l; reference interval [RI] 151–158 mmol/l), hyperchloremia (142 mmol/l; RI 117–126 mmol/l), azotemia (blood urea nitrogen 51 mg/dl; RI 18–33 mg/dl), creatinine 3.0 mg/dl (RI 1.1–2.2 mg/dl), hyperphosphatemia (8.3 mg/dl; RI 3.2–6.3 mg/dl) and total hypercalcemia (11.4 mg/dl; RI 9–10.9 mg/dl), with concurrent polyuria with adipsia. Neurologic evaluation revealed proprioceptive deficits, and this finding paired with a history of focal seizure-like activity despite improving sodium concentrations suggested a cerebrothalamic lesion. For this reason, and historical and biochemical findings consistent with adipsic diabetes insipidus (DI), MRI of the brain was performed, which revealed a lesion of the hypophyseal fossa consistent with a pituitary cyst. Given the patient’s age and the timeline of clinical signs, a congenital pituitary cyst was strongly suspected. The patient was managed initially with intravenous fluids to correct the hypernatremia, then managed for more than 4 years with topical ocular desmopressin acetate administration and free water administered through a feeding tube. This cat’s clinical diagnosis included a congenital pituitary cyst with subsequent central DI and primary adipsia.

Relevance and novel information

The clinical presentations of primary adipsia or central DI are both rare in cats. This is the first report to describe these conditions occurring in a cat owing to a congenital pituitary cyst and describes successful long-term management of this condition.

Adipsic Diabetes Insipidus-The Challenging Combination of Polyuria and Adipsia: A Case Report and Review of Literature

Adipsic Diabetes Insipidus is a rare hypothalamic disorder characterized by a loss of thirst in response to hypernatraemia accompanied by diabetes insipidus. These occur secondary to a congregation of defects in the homeostatic mechanisms of water balance. A 27-year old Chinese female presented with Adipsic Diabetes Insipidus after cerebral arteriovenous malformation (AVM) surgery. Initial diagnosis and management was extremely challenging. Long term management required a careful interplay between low dose vasopressin analog treatment and fluids. Detailed charts of medication and sodium balance are described in the case presentation. We performed a literature search of similarly reported cases and describe the possible pathogenesis, etiology, clinical presentation, acute and chronic management, and prognosis.

Central Diabetes Insipidus in Infancy With or Without Hypothalamic Adipsic Hypernatremia Syndrome: Early Identification and Outcome

CONTEXT

Neonatal central diabetes insipidus (CDI) with or without adipsia is a very rare complication of various complex hypothalamic disorders. It is associated with greater morbidity and a high risk of developing both hypernatremia and hyponatremia, due to the condition itself or secondary to treatment with vasopressin analogs or fluid administration. Its outcomes have yet to be evaluated.

OBJECTIVE

To investigate the clinical outcomes of patients with neonatal-onset CDI or adipsic CDI with hypernatremia.

DESIGN, SETTING, AND PARTICIPANTS

All patients diagnosed with neonatal CDI in a university hospital-based observational study and followed between 2005 and 2015 were included and analyzed retrospectively.

MAIN OUTCOME MEASURES

The various causes of CDI were grouped. Clinical outcome and comorbidities were analyzed.

RESULTS

Ten of the 12 patients had an underlying condition with brain malformations: optic nerve hypoplasia (n = 3), septo-optic dysplasia (n = 2), semilobar holoprosencephaly (n = 1), ectopic neurohypophysis (n = 3), and unilateral absence of the internal carotid artery (n = 1). The other two were idiopathic cases. During the median follow-up period of 7.8 (4.9-16.8) years, all but one patient displayed anterior pituitary deficiency. Transient CDI was found in three (25%) patients for whom a posterior pituitary hyperintense signal was observed with (n = 2) and without (n = 1) structural hypothalamic pituitary abnormalities, and with no other underlying cerebral malformations. Patients with permanent CDI with persistent adipsia (n = 4) and without adipsia (n = 5) required adequate fluid intake and various doses of desamino-D-arginine-8-vasopressin. Those with adipsia were more likely to develop hypernatremia (45 vs 33%), hyponatremia (16 vs 4%) (P < .0001), and severe neurodevelopmental delay (P < .05) than those without adipsia. Comorbidities were common. The underlying cause remains unknown at the age of 23 years for one patient with CDI and normal thirst.

CONCLUSION

Neonatal CDI may be transient or permanent. These vulnerable patients have high rates of comorbidity and require careful monitoring.

Posterior pituitary (PP) evaluation in patients with anterior pituitary defect associated with ectopic PP and septo-optic dysplasia

OBJECTIVE

Controversies exist about posterior pituitary (PP) function in subjects with ectopic PP (EPP) and with cerebral midline defects and/or their co-occurrence. We investigate water and electrolyte disturbances in patients at risk for PP dysfunction.

DESIGN

The study was conducted in a single Pediatric Endocrinology Research Unit.

METHODS

Forty-two subjects with childhood-onset GH deficiency were subdivided into five groups: normal magnetic resonance imaging (n=8, group 1); EPP (n=15, group 2); septo-optic dysplasia (SOD) with normal PP (n=4, group 3); EPP and SOD without (n=7, group 4), and with additional midline brain abnormalities (n=8, group 5). At a mean age of 16.0±1.1 years, they underwent a 120 min i.v. infusion with hypertonic 5% saline and evaluation of plasma osmolality (Posm), arginine vasopressin (AVP), thirst score (in groups 1 and 2), and urinary osmolality were performed.

RESULTS

Mean Posm and AVP significantly increased from baseline scores (284.7±4.9 mosm/kg and 0.6±0.2 pmol/l) to 120 min after saline infusion (300.5±8.0 mosm/kg and 10.3±3.3 pmol/l, P<0.0001). Group 5 showed higher mean Posm and lower mean AVP at all time points (P<0.0001). Mean thirst score did not show a significantly different trend between the groups 1 and 2. Urine osmolality was above 750 mosm/kg in all but seven patients after osmotic challenge.

CONCLUSIONS

Patients with midline brain abnormalities and EPP have defective osmoregulated AVP. Patients with EPP and congenital hypopituitarism have normal PP function.

Adipsic diabetes insipidus following pituitary surgery for a macroprolactinoma

Adipsic diabetes insipidus (ADI) is a rare condition in which thirst, an essential clinical feature for the prevention of hypernatraemic dehydration, is absent. We report the first case of adipsic diabetes insipidus to occur following surgery for a pituitary macroprolactinoma, with loss of both osmoregulated and baroregulated vasopressin release. Following extensive surgery for a vision threatening macroprolactinoma a 14-year-old boy developed profound hypernatraemia with absent thirst sensation. Detailed investigation, with hypertonic saline infusion and trimetaphan infusion, revealed absence of both osmoregulatory and baroregulatory release of vasopressin. We discuss the investigation and management of such patients and the physiology of hypothalamic-neurohypophyseal dysfunction in such patients.

Aspects cliniques des syndromes hypothalamiques idiopathiques : étude rétrospective et revue de la littérature

Hypothalamic obesity is usually induced by tumoral or genetic alterations such as craniopharyngioma or Prader-Willi syndrome, respectively. However, few cases have been reported without recognized etiology, this syndrome is also called idiopathic hypothalamic syndrome.

OBJECTIVES

To improve definition and frequency of complications associated with this syndrome.

POPULATION AND METHODS

A retrospective cohort study was performed in French endocrine paediatric departments and was associated with a literature review.

RESULTS

We report five cases of idiopathic hypothalamic syndrome. This syndrome is correlated with a high mortality (one of our five cases, 25% in the literature) by neurovegetative dysfunction (breathing or thermal alteration). Obesity began before six years old because of compulsive eating and resulted in social behaviour disorders. Abnormal endocrine secretions were characterized by early hyperprolactinemia, permanent but later somatotrope deficiency and 80% of thyreotrope deficiency. Puberty abnormalities included hypogonadotropic hypogonadism as well as precocious (one of our cases, three cases including literature) or normal puberty. Neurogenic hypernatremia and water and electrolytic disorders were also responsible of acute neurological alterations.

CONCLUSION

This largest study ever reported of idiopathic hypothalamic syndrome emphasizes the need of a multidisciplinary coordination to provide the best care of these patients.

Hypothalamic adipic hypernatraemia syndrome with normal osmoregulation of vasopressin

Adipsic hypernatraemia is an uncommon disorder in childhood caused by a defect in the osmoregulation of thirst, leading to impairment of water homeostasis and chronic hyperosmolality of body fluids. Adipsia is often associated with an abnormality in osmoregulated vasopressin secretion due to the close proximity of the hypothalamic osmoreceptors that control thirst with those regulating vasopressin secretion. Hypothalamic lesions of diverse aetiology (vascular abnormalities, neoplasms, granulomatous diseases, trauma etc.) have been described in this syndrome. We report a 12-year-old boy with evident weight loss due to hypernatraemic dehydration with a selective defect in osmoregulation of thirst and normal vasopressin secretion with no demonstrable structural lesion. To date, only six paediatric patients with this condition have been described in the literature.

CONCLUSION

Hypothalamic adipsic hypernatraemia syndrome must be suspected when a dehydrated patient denies thirst. The study of antidiuretic function is necessary because the osmoregulation of vasopressin secretion could be altered.

Hypernatraemia in early infancy

Hypernatraemia, defined as serum sodium > 150 mmol/l, is still seen frequently in tropical environments. We describe two infants, one with poor fluid intake and excessive wrapping and the other with a high solute intake, both of whom presented in a state of severe hypernatraemia. The pathophysiology of this condition is outlined, as are the major causes, such as sodium overload, inadequate water intake, increased water loss of non-renal origin, increased water loss of renal origin and essential hypernatraemia. The literature is reviewed and the current basis for management is appraised and discussed.

Adipsic hypernatremia syndrome in infancy

We report on an infant with chronic hypernatremia due to a congenital defect in osmo-regulation of thirst and the secretion of arginine vasopressin (AVP). A 12 month-old female infant who presented with irritability and signs of dehydration was found to have hypertonic dehydration; plasma osmolality was 430 mOsm/kg B.W. Despite rehydration she remained hypernatremic (serum Na+ 152-158 mEq/l). Lack of signs of thirst led us to the diagnosis of chronic hypernatremia due to adipsia. Laboratory investigation showed: 1. plasma AVP levels were low for plasma osmolality; 2. urine osmolality was normal for plasma AVP, and 3, there was a significant correlation of plasma to urine osmolality (r = 0.72, p < 0.02); however, the slope was markedly reduced indicating partial destruction of the AVP osmoreceptors.

Reversible vasopressin deficiency in severe hypernatremia

Studies to assess the relationship between plasma arginine vasopressin concentration (Pavp) and plasma osmolality (Posm) were performed on an elderly patient with dementia who developed severe hypernatremia due to inadequate water intake following a debilitating hip fracture. Serum sodium concentrations were 174 and 196 mEq/L on two consecutive hospital admissions. During the second of these admissions, sequential measurements of Pavp and Posm were obtained as hypernatremia was gradually corrected. Pavp during this period was correlated with Posm (r = 0.887, P < 0.01), but was low despite the presence of hyperosmolality and volume depletion. Pavp decreased from 0.56 microU/mL to 0.18 microU/mL as Posm decreased from 396 to 338 mOsm/kg H2O. The regression line of this relationship intercepted the abscissa at 320 mOsm/kg H2O. Hypertonic sodium chloride infusion to reassess this relationship 2 days following the correction of hypernatremia increased Pavp only to 0.67 microU/mL while increasing Posm from 297 to 316 mOsm/kg H2O. Nevertheless, Pavp and Posm were significantly correlated (r = 0.937, P < 0.001). The slope of the regression line was 0.031, and Posm at the abscissal intercept was 292 mOsm/kg H2O. A similar increase in Posm from 290 to 310 mOsm/kg H2O during hypertonic sodium chloride infusion 11 days following the correction of hypernatremia increased Pavp to 1.95 microU/mL (r = 0.786, P < 0.05). The magnitude of the increase in Pavp at this time was equivalent to that previously observed in studies of normal subjects. The slope (0.048) and abscissal intercept (280 mOsm/kg H2O) of linear regression were also consistent with observations in studies of normal subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypothalamic failure as a sequela of heterozygous protein C deficiency?

Protein C deficiency can lead to cerebrovascular occlusive disease. We describe a patient in whom heterozygous protein C deficiency (type 1) is suspected on the grounds of reduced protein C activity and who suffered from multiple thrombo-embolic events involving the brain and peripheral organs. The patient developed hypothalamic failure with hypernatraemia, hypodipsia, hypersomnolence and hyperkapnia, obesity, hyperprolactinaemia, hypogonadotropic hypogonadism and growth hormone deficiency. We hypothesize that protein C deficiency caused cerebrovascular occlusions which eventually led to hypothalamic insufficiency in this patient. Disorders of the anticoagulant system should be looked for in patients with unexplained hypothalamic disease.

Hypernatremia

Hypernatremia results when the water content of body fluids is deficient compared with sodium content. Hypernatremia can be the result of pure sodium excess but is usually associated with dehydration, secondary to excess losses of water or hypotonic fluids. Hypernatremic dehydration is less common than hyponatremic or isonatremic dehydration, but is associated with the highest morbidity and mortality rate, primarily related to CNS dysfunction. Except when hypernatremia has developed rapidly, the serum sodium concentration should be corrected slowly with frequent monitoring of serum electrolytes. Even then CNS damage can result, either as a consequence of the hypernatremia itself or of rapid lowering of the serum sodium concentration.

Inappropriate secretion of antidiuretic hormone, polydipsia and hypothalamic calcifications

We studied a 41 year old patient who had pathologic fluid intake of 10 1/day together with syndrome of inappropriate antidiuretic hormone. Imaging studies revealed a lesion of the anterior wall of the third cerebral ventricle. A review of relevant literature indicated several different disturbances by which alterations of thirst, vasopressin-secretion and abnormalities of anterior third ventricle may be associated. The present case presents an unusual and potentially dangerous combination in this spectrum of changes.

Hypodipsic hypernatremia associated with absence of septum lucidum and olfactory dysfunction

A case of hypodipsic hypernatremia in a 16-month-old Japanese boy is reported. Partial antidiuretic hormone deficiency was present. Computed tomography of the brain revealed absence of septum lucidum. No ophthalmological abnormality could be found. He had hyposmia, which has not been reported previously in association with hypernatremia due to hypodipsia. Forced fluid administration and nasal 1-deamino-8-d-arginine vasopressin treatment could maintain serum electrolyte levels within normal ranges. However, episodes of hypernatremia could not be completely avoided while he was treated with 1-deamino-8-d-arginine vasopressin and ad libitum oral fluid.

Determinants of plasma arginine-vasopressin in children

Plasma concentration of arginine-vasopressin (AVP) was measured in 145 healthy subjects aged one day to 18 years of age. AVP decreased with age immediately after birth. Above one year of age values of children did not significantly differ from those in adults. AVP significantly correlated with plasma and urine osmolality after water deprivation during 16 h. Plasma AVP rose during exercise and fell after volume expansion. Nausea and vomiting are potent nonosmotic determinants of AVP release in children. Nonosmotic factors of AVP release should be controlled when sampling blood for measuring AVP in children for diagnostic and investigational purposes.

Lack of thirst, osmoreceptor dysfunction, early puberty and abnormally aggressive behaviour in two boys

Two unrelated boys (C.C. 13 years; J.W. 18 years) presenting with early puberty and episodes of aggressive behaviour were found to have hypernatraemia and hypodipsia. Plasma vasopressin (AVP) levels were inappropriately low in relation to plasma osmolality, but the patients did not have diabetes insipidus since 24 h urinary volumes were less than 1 litre and the maximal urinary osmolality was 1232 in C.C. and 950 in J.W. Plasma renin activity was elevated (greater than 2000 mg AI/1/h) although aldosterone concentrations were normal. Excretion of a water load (20 ml/kg) was delayed, but plasma renin and aldosterone fell with increased naturesis. An infusion of 0.85 mol/l saline produced a rise in AVP in C.C. but not in J.W. Insulin and hypotension resulted in the release of AVP in both boys suggesting a selective defect of osmoreceptor function. Hyperprolactinaemia and an exaggerated PRL response to TRH were also noted but no intracranial lesion was demonstrable on CT scan. These boys appear to have a hypothalamic syndrome with early puberty, hyperprolactinaemia, hypodipsia and osmoreceptor dysfunction which may be associated with aggressive behaviour.