1
|
Barnett MJ, Patel G, Lekprasert P, Win K, Casipit C, Syed O. 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. Cureus 2024; 16:e64207. [PMID: 38993626 PMCID: PMC11239235 DOI: 10.7759/cureus.64207] [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: 07/10/2024] [Indexed: 07/13/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Maxim J Barnett
- Internal Medicine, Jefferson Einstein Hospital, Philadelphia, USA
| | - Goonja Patel
- Endocrinology, Jefferson Einstein Hospital, Philadelphia, USA
| | | | - Kay Win
- Endocrinology, Diabetes and Metabolism, Jefferson Einstein Hospital, Philadelphia, USA
| | - Carlo Casipit
- Internal Medicine, Jefferson Einstein Hospital, Philadelphia, USA
| | - Osama Syed
- Radiology, Jefferson Einstein Hospital, Philadelphia, USA
| |
Collapse
|
2
|
Segoe H, Nakamura A, Uetake K, Hishimura N, Kaneko N, Morikawa S, Nakamura-Utsunomiya A, Yamaguchi T. Adipsic hypernatremia with marked hyperprolactinemia and GH deficiency in a 9-year-old boy. Clin Pediatr Endocrinol 2024; 33:163-168. [PMID: 38993721 PMCID: PMC11234189 DOI: 10.1297/cpe.2024-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/28/2024] [Indexed: 07/13/2024] Open
Abstract
Adipsic hypernatremia is typically caused by congenital dysplasia of the hypothalamus and pituitary or brain tumors. However, cases of adipsic hypernatremia without underlying organic abnormalities are rare, and some cases have been reported to be complicated by hypothalamic-pituitary dysfunction. The patient in this case was a 9-yr-old boy who was referred to our hospital because of hypernatremia. His growth chart revealed that he had rapidly become obese since infancy, with growth retardation since the age of seven. His hands and feet were very cold, and he had erythema on his abdomen, indicating possible autonomic dysregulation due to hypothalamic dysfunction. Several hormone load tests showed severe GH deficiency (GHD) and marked hyperprolactinemia (peak: 302.8 ng/mL). Magnetic resonance imaging revealed no organic abnormalities in the hypothalamus and pituitary gland. GH replacement therapy was initiated. Although his growth rate improved, obesity persisted. To the best of our knowledge, this is the first report of adipsic hypernatremia without organic intracranial abnormalities that was treated with GH. Moreover, the patient's prolactin levels were higher than those reported in previous studies. In conclusion, adipsic hypernatremia requires the evaluation of pituitary function and appropriate therapeutic interventions.
Collapse
Affiliation(s)
- Hisato Segoe
- Department of Pediatrics, Obihiro-Kosei Hospital, Obihiro, Japan
| | - Akie Nakamura
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kimiaki Uetake
- Department of Pediatrics, Obihiro-Kosei Hospital, Obihiro, Japan
| | - Nozomi Hishimura
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Naoya Kaneko
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Shuntaro Morikawa
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Akari Nakamura-Utsunomiya
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
- Department of Pediatrics, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan
| | - Takeshi Yamaguchi
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- Center for Environmental and Health Sciences, Hokkaido University, Sapporo, Japan
| |
Collapse
|
3
|
Hiyama TY. Brain sodium sensing for regulation of thirst, salt appetite, and blood pressure. Physiol Rep 2024; 12:e15970. [PMID: 38479999 PMCID: PMC10937250 DOI: 10.14814/phy2.15970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 02/29/2024] [Indexed: 03/17/2024] Open
Abstract
The brain possesses intricate mechanisms for monitoring sodium (Na) levels in body fluids. During prolonged dehydration, the brain detects variations in body fluids and produces sensations of thirst and aversions to salty tastes. At the core of these processes Nax , the brain's Na sensor, exists. Specialized neural nuclei, namely the subfornical organ (SFO) and organum vasculosum of the lamina terminalis (OVLT), which lack the blood-brain barrier, play pivotal roles. Within the glia enveloping the neurons in these regions, Nax collaborates with Na+ /K+ -ATPase and glycolytic enzymes to drive glycolysis in response to elevated Na levels. Lactate released from these glia cells activates nearby inhibitory neurons. The SFO hosts distinct types of angiotensin II-sensitive neurons encoding thirst and salt appetite, respectively. During dehydration, Nax -activated inhibitory neurons suppress salt-appetite neuron's activity, whereas salt deficiency reduces thirst neuron's activity through cholecystokinin. Prolonged dehydration increases the Na sensitivity of Nax via increased endothelin expression in the SFO. So far, patients with essential hypernatremia have been reported to lose thirst and antidiuretic hormone release due to Nax -targeting autoantibodies. Inflammation in the SFO underlies the symptoms. Furthermore, Nax activation in the OVLT, driven by Na retention, stimulates the sympathetic nervous system via acid-sensing ion channels, contributing to a blood pressure elevation.
Collapse
Affiliation(s)
- Takeshi Y. Hiyama
- Department of Integrative PhysiologyTottori University Graduate School and Faculty of MedicineYonagoJapan
| |
Collapse
|
4
|
Tocan V, Nakamura-Utsunomiya A, Sonoda Y, Matsuoka W, Mizuguchi S, Muto Y, Hijioka T, Nogami M, Sasaoka D, Nagamatsu F, Oba U, Kawakubo N, Hamada H, Mushimoto Y, Chong PF, Kaku N, Koga Y, Sakai Y, Oda Y, Tajiri T, Ohga S. High-Titer Anti-ZSCAN1 Antibodies in a Toddler Clinically Diagnosed with Apparent Rapid-Onset Obesity with Hypothalamic Dysfunction, Hypoventilation, and Autonomic Dysregulation Syndrome. Int J Mol Sci 2024; 25:2820. [PMID: 38474067 DOI: 10.3390/ijms25052820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/24/2024] [Accepted: 02/25/2024] [Indexed: 03/14/2024] Open
Abstract
Severe obesity in young children prompts for a differential diagnosis that includes syndromic conditions. Rapid-Onset Obesity with Hypothalamic Dysfunction, Hypoventilation, and Autonomic Dysregulation (ROHHAD) syndrome is a potentially fatal disorder characterized by rapid-onset obesity associated with hypoventilation, neural crest tumors, and endocrine and behavioral abnormalities. The etiology of ROHHAD syndrome remains to be established, but recent research has been focusing on autoimmunity. We report on a 2-year-old girl with rapid-onset obesity during the first year of life who progressed to hypoventilation and encephalitis in less than four months since the start of accelerated weight gain. The patient had a high titer of anti-ZSCAN1 antibodies (348; reference range < 40), and the increased values did not decline after acute phase treatment. Other encephalitis-related antibodies, such as the anti-NDMA antibody, were not detected. The rapid progression from obesity onset to central hypoventilation with encephalitis warns about the severe consequences of early-onset ROHHAD syndrome. These data indicate that serial measurements of anti-ZSCAN1 antibodies might be useful for the diagnosis and estimation of disease severity. Further research is needed to determine whether it can predict the clinical course of ROHHAD syndrome and whether there is any difference in antibody production between patients with and without tumors.
Collapse
Affiliation(s)
- Vlad Tocan
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Akari Nakamura-Utsunomiya
- Department of Genetic Medicine/Pediatrics, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8511, Japan
- Department of Pediatrics, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima 731-0293, Japan
- Division of Neonatal Screening, National Center for Child Health and Development, Tokyo 157-8535, Japan
| | - Yuri Sonoda
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Wakato Matsuoka
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
- Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Soichi Mizuguchi
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
- Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Yuichiro Muto
- Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan
| | - Takaaki Hijioka
- Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | - Masao Nogami
- Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan
| | - Daiki Sasaoka
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | - Fusa Nagamatsu
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | - Utako Oba
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Naonori Kawakubo
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Hiroshi Hamada
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Yuichi Mushimoto
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Pin Fee Chong
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Noriyuki Kaku
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
- Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Yuhki Koga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Yasunari Sakai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Tatsuro Tajiri
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| |
Collapse
|
5
|
Nakamura-Utsunomiya A, Yamaguchi K, Goshima N. Anti-ZSCAN1 Autoantibodies Are a Feasible Diagnostic Marker for ROHHAD Syndrome Not Associated with a Tumor. Int J Mol Sci 2024; 25:1794. [PMID: 38339072 PMCID: PMC10855538 DOI: 10.3390/ijms25031794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/28/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
Recent studies have reported the presence of autoantibodies against zinc finger and SCAN domain-containing protein 1 (ZSCAN1) in the sera of patients with rapid-onset obesity with hypoventilation, hypothalamic and autonomic dysregulation (ROHHAD) syndrome associated with neuroendocrine tumors, suggesting immunologic and paraneoplastic processes as the pathologic underpinnings. Moreover, several hypothalamic regions, including the subfornical organ (SFO), were reported to exhibit antibody reactivity in a patient with ROHHAD syndrome not associated with a tumor. Whether ROHHAD syndrome not associated with a tumor is associated with anti-ZSCAN1 autoantibodies remains unclear. We used a comprehensive protein array analysis to identify candidate molecules in the sera of patients with ROHHAD syndrome and identified ZSCAN1 as a target antigen. We also found that ZSCAN1 was co-expressed at the site of antibody reactivity to the IgG in the patient serum observed in mouse SFOs and an enzyme-linked immunosorbent assay showed that >85% of the patients with ROHHAD syndrome were positive for anti-ZSCAN1 autoantibodies. These results suggest anti-ZSCAN1 autoantibodies as a feasible diagnostic marker in ROHHAD syndrome regardless of the presence of a tumor.
Collapse
Affiliation(s)
- Akari Nakamura-Utsunomiya
- Department of Pediatrics/Medical Genetics, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan
- Department of Pediatrics, Hiroshima Medical Center, Asa Citizens Hospital, Hiroshima 731-0293, Japan
- Division of Neonatal Screening, National Center for Child Health and Development, Tokyo 157-8535, Japan
| | - Kei Yamaguchi
- Molecular Profiling Research Center for Drug Discovery, National Institute of Advanced Industrial Science and Technology, Tokyo 135-0064, Japan
- ProteoBridge Corporation, Tokyo 135-0064, Japan
| | - Naoki Goshima
- Molecular Profiling Research Center for Drug Discovery, National Institute of Advanced Industrial Science and Technology, Tokyo 135-0064, Japan
- ProteoBridge Corporation, Tokyo 135-0064, Japan
| |
Collapse
|
6
|
Liebrand M, Rebsamen M, Nakamura-Utsunomiya A, von den Driesch L, Köck P, Caccia J, Hamann C, Wiest R, Kaess M, Walther S, Tschumi S, Hiyama TY, Kindler J. Case report: Psychosis and catatonia in an adolescent patient with adipsic hypernatremia and autoantibodies against the subfornical organ. Front Psychiatry 2023; 14:1206226. [PMID: 37539324 PMCID: PMC10396436 DOI: 10.3389/fpsyt.2023.1206226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 07/03/2023] [Indexed: 08/05/2023] Open
Abstract
This is the first description of a patient in which adipsic hypernatremia, a rare autoimmune encephalitis, presented in combination with complex psychiatric symptomatology, including psychosis and catatonia. Adipsic hypernatremia is characterized by autoantibodies against the thirst center of the brain. These autoantibodies cause inflammation and apoptosis in key regions of water homeostasis, leading to lack of thirst and highly increased serum sodium. To date, the symptoms of weakness, fatigue and drowsiness have been associated with adipsic hypernatremia, but no psychiatric symptomatology. Here, we showcase the first description of an adolescent patient, in which severe and complex psychiatric symptoms presented along with adipsic hypernatremia. The patient experienced delusion, hallucinations, restlessness and pronounced depression. Further, he showed ritualized, aggressive, disinhibited and sexualized behavior, as well as self-harm and psychomotor symptoms. Due to his severe condition, he was hospitalized on the emergency unit of the child and adolescent psychiatry for 8 months. Key symptoms of the presented clinical picture are: childhood-onset complex and treatment-resistant psychosis/catatonia, pronounced behavioral problems, fatigue, absent thirst perception, hypernatremia and elevated prolactin levels. This case report renders first evidence speaking for a causal link between the autoimmune adipsic hypernatremia and the psychotic disorder. Moreover, it sheds light on a new form of autoimmune psychosis.
Collapse
Affiliation(s)
- Matthias Liebrand
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Michael Rebsamen
- Support Center for Advanced Neuroimaging (SCAN), University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Akari Nakamura-Utsunomiya
- Department of Medical Genetics and Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Luisa von den Driesch
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Patrick Köck
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Julien Caccia
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Hamann
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roland Wiest
- Support Center for Advanced Neuroimaging (SCAN), University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Kaess
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
- Department of Child and Adolescent Psychiatry, Center for Psychosocial Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Sebastian Walther
- Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Sibylle Tschumi
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Takeshi Y. Hiyama
- Department of Integrative Physiology, Graduate School and Faculty of Medicine, Tottori University, Tottori, Japan
| | - Jochen Kindler
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| |
Collapse
|
7
|
Fabre L, da Silva VC. Idiopathic partial central diabetes insipidus. EINSTEIN-SAO PAULO 2023; 21:eRC0124. [PMID: 36790249 PMCID: PMC9897711 DOI: 10.31744/einstein_journal/2023rc0124] [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] [Received: 04/04/2022] [Accepted: 09/18/2022] [Indexed: 01/31/2023] Open
Abstract
Diabetes insipidus is a rare disorder characterized by the inability to concentrate urine, which results in hypotonic urine and increased urinary volume. It may occur because of antidiuretic hormone deficiency or resistance to its action in the renal tubules. When there is a deficiency in the synthesis of antidiuretic hormones, diabetes insipidus is called central; when there is resistance to its action in the renal tubules, it is said to be nephrogenic. We report a case of idiopathic partial central diabetes insipidus and highlight the management and treatment of the disease.
Collapse
Affiliation(s)
- Larissa Fabre
- Hospital Regional Hans Dieter SchmidtJoinvilleSCBrazil Hospital Regional Hans Dieter Schmidt, Joinville, SC, Brazil.
| | - Viviane Calice da Silva
- Hospital Regional Hans Dieter SchmidtJoinvilleSCBrazil Hospital Regional Hans Dieter Schmidt, Joinville, SC, Brazil.
| |
Collapse
|
8
|
Eyduran E, Kaymaz B, Ince G, Kanık A. A rare cause of hypernatremia in an adolescent girl: Answers. Pediatr Nephrol 2022; 37:2333-2335. [PMID: 35288795 DOI: 10.1007/s00467-022-05509-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 01/28/2022] [Accepted: 01/28/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Eda Eyduran
- Department of Pediatrics, Izmir University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey.
| | - Berkay Kaymaz
- Department of Pediatrics, Izmir University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
| | - Gülberat Ince
- Department of Pediatrics, Izmir University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
| | - Ali Kanık
- Department of Pediatrics, Izmir University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey.,Department of Pediatrics, Izmir Katip Çelebi University, Izmir, Turkey
| |
Collapse
|
9
|
Nakamura-Utsunomiya A, Goda S, Hayakawa S, Sonoko S, Hoorn EJ, Blanchard A, Saito-Hakoda A, Kakimoto H, Hachiya R, Kamimura M, Kawakita R, Higuchi S, Fujimaru R, Shirai Y, Miyaoka D, Nagata Y, Kishi Y, Wada A, Mitsuboshi A, Ozaki K, Komatsu N, Niizuma H, Kanno J, Fujiwara I, Hasegawa Y, Yorifuji T, Brickman W, Vantyghem MC, Yamaguchi K, Goshima N, Hiyama TY. Identification of clinical factors related to antibody-mediated immune response to the subfornical organ. Clin Endocrinol (Oxf) 2022; 97:72-80. [PMID: 35419873 DOI: 10.1111/cen.14737] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 02/28/2022] [Accepted: 04/06/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We recently reported cases of adipsic hypernatremia caused by autoantibodies against the subfornical organ in patients with hypothalamic-pituitary lesions. This study aimed to clarify the clinical features of newly identified patients with adipsic hypernatremia whose sera displayed immunoreactivity to the mouse subfornical organ. DESIGN Observational cohort study of patients diagnosed with adipsic hypernatremia in Japan, United States, and Europe. METHODS The study included 22 patients with adipsic hypernatremia but without overt structural changes in the hypothalamic-pituitary region and congenital disease. Antibody response to the mouse subfornical organ was determined using immunohistochemistry. The clinical characteristics were compared between the patients with positive and negative antibody responses. RESULTS Antibody response to the mouse subfornical organ was detected in the sera of 16 patients (72.7%, female/male ratio, 1:1, 12 pediatric and 4 adult patients). The prolactin levels at the time of diagnosis were significantly higher in patients with positive subfornical organ (SFO) immunoreactivity than in those with negative SFO immunoreactivity (58.9 ± 33.5 vs. 22.9 ± 13.9 ng/ml, p < .05). Hypothalamic disorders were found in 37.5% of the patients with positive SFO immunoreactivity. Moreover, six patients were diagnosed with rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation/neural tumor syndrome after the diagnosis of adipsic hypernatremia. Plasma renin activity levels were significantly higher in patients with serum immunoreactivity to the Nax channel. CONCLUSIONS The patients with serum immunoreactivity to the SFO had higher prolactin levels and hypothalamic disorders compared to those without the immunoreactivity. The clinical characteristics of patients with serum immunoreactivity to the subfornical organ included higher prolactin levels and hypothalamic disorders, which were frequently associated with central hypothyroidism and the presence of retroperitoneal tumors.
Collapse
Affiliation(s)
- Akari Nakamura-Utsunomiya
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
- Department of Pediatrics, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Satoshi Goda
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Seiichi Hayakawa
- Department of Pediatrics, Hiroshima University Hospital, Hiroshima, Japan
| | - Sakata Sonoko
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Ewout J Hoorn
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Anne Blanchard
- Center of Clinical investigation, Faculty of Medicine, Hospital European George Pompidou Paris, Paris, France
| | | | - Haruna Kakimoto
- Department of Pediatrics, Kagoshima University Hospital, Kagoshima, Japan
| | - Rumi Hachiya
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Miki Kamimura
- Department of Pediatrics, Tohoku University Hospital, Sendai, Japan
| | - Rie Kawakita
- Division of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Shinji Higuchi
- Division of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Rika Fujimaru
- Department of Pediatrics, Osaka City General Hospital, Osaka, Japan
| | - Yoko Shirai
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Daichi Miyaoka
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yuki Nagata
- Department of Vascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
- Department of vascular medicine, Vascular Science Center for Translational Research, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yutaro Kishi
- Department of Endocrinology and Metabolism, Niigata University Medical and Dentist Hospital, Niigata, Japan
| | - Aya Wada
- Department of Pediatrics, Gunma University Hospital, Tochigi, Japan
| | - Akari Mitsuboshi
- Division of Endocrinology and Metabolism, Hyogo Prefectural Kobe children's Hospital, Kobe, Japan
| | - Kayo Ozaki
- Division of Endocrinology and Metabolism, Hyogo Prefectural Kobe children's Hospital, Kobe, Japan
| | - Nagisa Komatsu
- Department of Pediatrics, Kumamoto Chuo Hospital, Kumamoto, Japan
| | - Hidetaka Niizuma
- Department of Pediatrics, Tohoku University Hospital, Sendai, Japan
| | - Junko Kanno
- Department of Pediatrics, Tohoku University Hospital, Sendai, Japan
| | - Ikuma Fujiwara
- Department of Pediatrics, Tohoku University Hospital, Sendai, Japan
| | - Yukihiro Hasegawa
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Tohru Yorifuji
- Division of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Wendy Brickman
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Endocrinology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Marie-Christine Vantyghem
- Department of Endocrinology, Diabetology, Metabolism and Nutrition, Lille University Hospital, Lille, France
| | - Kei Yamaguchi
- Molecular Profiling Research Center for Drug Discovery, National Institute of Advanced Industrial Science and Technology, Tokyo, Japan
- ProteoBridge Corporation, Tokyo, Japan
| | - Naoki Goshima
- Molecular Profiling Research Center for Drug Discovery, National Institute of Advanced Industrial Science and Technology, Tokyo, Japan
- ProteoBridge Corporation, Tokyo, Japan
| | - Takeshi Y Hiyama
- Department of Cellular Physiology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| |
Collapse
|
10
|
Nakamura-Utsunomiya A. Autoimmunity Related to Adipsic Hypernatremia and ROHHAD Syndrome. Int J Mol Sci 2022; 23:ijms23136899. [PMID: 35805903 PMCID: PMC9266522 DOI: 10.3390/ijms23136899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/18/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
Specific antibody responses to subfornical organs, including Nax antibody, have been reported in patients with adipsic hypernatremia of unknown etiology who do not have structural lesions in the hypothalamic–pituitary gland. The subfornical organ, also referred to as the window of the brain, is a sensing site that monitors sodium and osmotic pressure levels. On the other hand, ROHHAD syndrome is a rare disease for which the etiology of the hypothalamic disorder is unknown, and there have been some reports in recent years describing its association with autoimmune mechanisms. In addition, abnormal Na levels, including hypernatremia, are likely to occur in this syndrome. When comparing the clinical features of adipsic hypernatremia due to autoimmune mechanisms and ROHHAD syndrome, there are similar hypothalamic–pituitary dysfunction symptoms in addition to abnormal Na levels. Since clinical diagnoses of autoimmunological adipsic hypernatremia and ROHAD syndrome might overlap, we need to understand the essential etiology and carry out precise assessments to accurately diagnose patients and provide effective treatment. In this review, I review the literature on the autoimmune mechanism reported in recent years and describe the findings obtained so far and future directions.
Collapse
Affiliation(s)
- Akari Nakamura-Utsunomiya
- Department of Genetic Medicine, Hiroshima University Graduate School, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8511, Japan;
- Department of Pediatrics, Hiroshima University Graduate School, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8511, Japan
- Division of Neonatal Screening, National Center for Child Health and Development, 2 Chome-10-1 Okura, Setagaya, Tokyo 157-8535, Japan
| |
Collapse
|
11
|
Patti G, Napoli F, Fava D, Casalini E, Di Iorgi N, Maghnie M. Approach to the Pediatric Patient: Central Diabetes Insipidus. J Clin Endocrinol Metab 2022; 107:1407-1416. [PMID: 34993537 DOI: 10.1210/clinem/dgab930] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Indexed: 11/19/2022]
Abstract
Central diabetes insipidus (CDI) is a complex disorder in which large volumes of dilute urine are excreted due to arginine-vasopressin deficiency, and it is caused by a variety of disorders affecting the hypothalamic-posterior pituitary network. The differential diagnosis is challenging and requires a detailed medical history, physical examination, biochemical approach, imaging studies, and, in some cases, histological confirmation. Magnetic resonance imaging is the gold standard method for evaluating congenital or acquired cerebral and pituitary stalk lesions. Pituitary stalk size at presentation could be normal, but it may change over time, depending on the underlying condition, while other brain areas or organs may become involved during follow-up. Early diagnosis and treatment are crucial to avoid central nervous system damage and germ cell tumor dissemination and to minimize complications of multiple pituitary hormone defects. We provide a practical update on the diagnosis and management of patients with CDI and highlight several pitfalls that may complicate the differential diagnosis of conditions presenting with polyuria and polydipsia. The need for a careful and close follow-up of patients with apparently idiopathic CDI is particularly emphasized because the underlying condition may be recognized over time. The clinical scenario that we outline at the beginning of this article represents the basis for the discussion about how the etiological diagnosis of CDI can be overlooked and demonstrates how a water intake and urine output improvement can be a sign of progressive damage of both hypothalamus and anterior pituitary gland with associated pituitary hormonal deficiencies.
Collapse
Affiliation(s)
- Giuseppa Patti
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Flavia Napoli
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Daniela Fava
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Emilio Casalini
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Natascia Di Iorgi
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Mohamad Maghnie
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| |
Collapse
|
12
|
Akashi Y, Park YT, Oetelaar GS, Murakami M. Successful treatment of hypodipsic/adipsic hypernatremia in a cat with lobar holoprosencephaly using oral desmopressin. JFMS Open Rep 2022; 8:20551169221082542. [PMID: 35342639 PMCID: PMC8949744 DOI: 10.1177/20551169221082542] [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] [Indexed: 11/16/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Yoriko Akashi
- Ve C Jiyugaoka Animal Medical Center, Meguro City, Tokyo, Japan
| | - Young Tae Park
- Ve C Jiyugaoka Animal Medical Center, Meguro City, Tokyo, Japan
| | - Garrett S Oetelaar
- VCA Canada CARE Centre, Calgary, AB, Canada.,Department of Veterinary Clinical Sciences, Purdue University, West Lafayette, IN, USA
| | - Masahiro Murakami
- Department of Veterinary Clinical Sciences, Purdue University, West Lafayette, IN, USA
| |
Collapse
|
13
|
NODA M, MATSUDA T. Central regulation of body fluid homeostasis. PROCEEDINGS OF THE JAPAN ACADEMY. SERIES B, PHYSICAL AND BIOLOGICAL SCIENCES 2022; 98:283-324. [PMID: 35908954 PMCID: PMC9363595 DOI: 10.2183/pjab.98.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Extracellular fluids, including blood, lymphatic fluid, and cerebrospinal fluid, are collectively called body fluids. The Na+ concentration ([Na+]) in body fluids is maintained at 135-145 mM and is broadly conserved among terrestrial animals. Homeostatic osmoregulation by Na+ is vital for life because severe hyper- or hypotonicity elicits irreversible organ damage and lethal neurological trauma. To achieve "body fluid homeostasis" or "Na homeostasis", the brain continuously monitors [Na+] in body fluids and controls water/salt intake and water/salt excretion by the kidneys. These physiological functions are primarily regulated based on information on [Na+] and relevant circulating hormones, such as angiotensin II, aldosterone, and vasopressin. In this review, we discuss sensing mechanisms for [Na+] and hormones in the brain that control water/salt intake behaviors, together with the responsible sensors (receptors) and relevant neural pathways. We also describe mechanisms in the brain by which [Na+] increases in body fluids activate the sympathetic neural activity leading to hypertension.
Collapse
Affiliation(s)
- Masaharu NODA
- Homeostatic Mechanism Research Unit, Institute of Innovative Research, Tokyo Institute of Technology, Yokohama, Kanagawa, Japan
- Correspondence should be addressed to: Homeostatic Mechanism Research Unit, Institute of Innovative Research, Tokyo Institute of Technology, Nagatsuta-cho 4259, Midori-ku, Yokohama, Kanagawa 226-8503, Japan (e-mail: )
| | - Takashi MATSUDA
- Homeostatic Mechanism Research Unit, Institute of Innovative Research, Tokyo Institute of Technology, Yokohama, Kanagawa, Japan
| |
Collapse
|
14
|
Aamodt K, Fitzgerald SL, Hanono A, Majzoub J, Millington K, Richmond TK, Peeler KR. Severe Hypernatremia in an Adolescent With Anorexia Nervosa. Clin Pediatr (Phila) 2021; 60:586-590. [PMID: 34706583 PMCID: PMC10150912 DOI: 10.1177/00099228211055283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Kristie Aamodt
- Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Shannon L Fitzgerald
- Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Anat Hanono
- Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Joseph Majzoub
- Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Kate Millington
- Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Tracy K Richmond
- Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Katherine R Peeler
- Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| |
Collapse
|
15
|
Abstract
Diabetes insipidus (DI) is a disorder characterized by a high hypotonic urinary output of more than 50ml per kg body weight per 24 hours, with associated polydipsia of more than 3 liters a day [1,2]. Central DI results from inadequate secretion and usually deficient synthesis of Arginine vasopressin (AVP) in the hypothalamus or pituitary gland. Besides central DI further underlying etiologies of DI can be due to other primary forms (renal origin) or secondary forms of polyuria (resulting from primary polydipsia). All these forms belong to the Polyuria Polydipsia Syndrom (PPS). In most cases central and nephrogenic DI are acquired, but there are also congenital forms caused by genetic mutations of the AVP gene (central DI) [3] or by mutations in the gene for the AVP V2R or the AQP2 water channel (nephrogenic DI) [4]. Primary polydipsia (PP) as secondary form of polyuria includes an excessive intake of large amounts of fluid leading to polyuria in the presence of intact AVP secretion and appropriate antidiuretic renal response. Differentiation between the three mentioned entities is difficult [5], especially in patients with Primary polydipsia or partial, mild forms of DI [1,6], but different tests for differential diagnosis, most recently based on measurement of copeptin, and a thorough medical history mostly lead to the correct diagnosis. This is important since treatment strategies vary and application of the wrong treatment can be dangerous [7]. Treatment of central DI consists of fluid management and drug therapy with the synthetic AVP analogue Desmopressin (DDAVP), that is used as nasal or oral preparation in most cases. Main side effect can be dilutional hyponatremia [8]. In this review we will focus on central diabetes insipidus and describe the prevalence, the clinical manifestations, the etiology as well as the differential diagnosis and management of central diabetes insipidus in the out- and inpatient setting.
Collapse
|
16
|
Shirai Y, Miura K, Nakamura-Utsunomiya A, Ishizuka K, Hattori M, Hattori M. Analysis of water and electrolyte imbalance in a patient with adipsic hypernatremia associated with subfornical organ-targeting antibody. CEN Case Rep 2021; 11:110-115. [PMID: 34420198 DOI: 10.1007/s13730-021-00638-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/16/2021] [Indexed: 11/27/2022] Open
Abstract
Patients with adipsic hypernatremia present with chronic hypernatremia because of defects in thirst sensation and dysregulated salt appetite, without demonstrable hypothalamic structural lesions. The involvement of autoantibodies directed against the sodium channel, Nax in the subfornical organ (SFO) has recently been reported. However, the pathophysiology of water and electrolyte imbalance underlying the disease has yet to be elucidated. We describe the case of a 5-year-old boy who complained of headaches and vomiting that gradually worsened. Brain magnetic resonance imaging detected no abnormal lesions. Blood laboratory testing revealed a serum sodium (Na) concentration of 152 mmol/L and a serum osmolarity of 312 mOsm/L. His body weight had slightly decreased, and his thirst sensation was absent. His plasma vasopressin concentration was 0.9 pg/mL, despite the high serum osmolarity. He was encouraged to drink water, and oral 1-deamino-8-D-arginine-vasopressin was administered. When serum sodium concentrations were normalized, plasma vasopressin concentrations were apparently normal and ranged from 0.8 to 2.0 pg/mL. He did not present with polyuria at any time. Immunohistochemical study using mouse brain sections and the patient's serum revealed the deposition of human immunoglobulin G (IgG) antibody in the mouse SFO. In conclusion, our observations suggested that water and electrolyte imbalance in adipsic hypernatremia is characterized by a certain amount of vasopressin release regardless of serum sodium concentrations with no response to hyperosmolarity.
Collapse
Affiliation(s)
- Yoko Shirai
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
- Department of Pediatrics, Toho University Medical Center Ohashi Hospital, Tokyo, Japan
| | - Kenichiro Miura
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan.
| | - Akari Nakamura-Utsunomiya
- Department of Pediatrics, Hiroshima Prefectural Hospital, Hiroshima, Japan
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Kiyonobu Ishizuka
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
| | - Miku Hattori
- Department of Pediatrics, Toho University Medical Center Ohashi Hospital, Tokyo, Japan
| | - Motoshi Hattori
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan
| |
Collapse
|
17
|
Fry WM, Ferguson AV. The subfornical organ and organum vasculosum of the lamina terminalis: Critical roles in cardiovascular regulation and the control of fluid balance. HANDBOOK OF CLINICAL NEUROLOGY 2021; 180:203-215. [PMID: 34225930 DOI: 10.1016/b978-0-12-820107-7.00013-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In this chapter, we review the extensive literature describing the roles of the subfornical organ (SFO), the organum vasculosum of the terminalis (OVLT), and the median preoptic nucleus (MnPO), comprising the lamina terminalis, in cardiovascular regulation and the control of fluid balance. We present this information in the context of both historical and technological developments which can effectively be overlaid upon each other. We describe intrinsic anatomy and connectivity and then discuss early work which described how circulating angiotensin II acts at the SFO to stimulate drinking and increase blood pressure. Extensive studies using direct administration and lesion approaches to highlight the roles of all regions of the lamina terminalis are then discussed. At the cellular level we describe c-Fos and electrophysiological work, which has highlighted an extensive group of circulating hormones which appear to influence the activity of specific neurons in the SFO, OVLT, and MnPO. We highlight optogenetic studies that have begun to unravel the complexities of circuitries underlying physiological outcomes, especially those related to different components of drinking. Finally, we describe the somewhat limited human literature supporting conclusions that these structures play similar and potentially important roles in human physiology.
Collapse
Affiliation(s)
- W Mark Fry
- Department of Biological Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Alastair V Ferguson
- Department of Biomedical and Molecular Sciences and Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada.
| |
Collapse
|
18
|
Driano JE, Lteif AN, Creo AL. Vasopressin-Dependent Disorders: What Is New in Children? Pediatrics 2021; 147:peds.2020-022848. [PMID: 33795481 DOI: 10.1542/peds.2020-022848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2021] [Indexed: 11/24/2022] Open
Abstract
Arginine vasopressin (AVP)-mediated osmoregulatory disorders, such as diabetes insipidus (DI) and syndrome of inappropriate secretion of antidiuretic hormone (SIADH) are common in the differential diagnosis for children with hypo- and hypernatremia and require timely recognition and treatment. DI is caused by a failure to concentrate urine secondary to impaired production of or response to AVP, resulting in hypernatremia. Newer methods of diagnosing DI include measuring copeptin levels; copeptin is AVP's chaperone protein and serves as a surrogate biomarker of AVP secretion. Intraoperative copeptin levels may also help predict the risk for developing DI after neurosurgical procedures. Copeptin levels hold diagnostic promise in other pediatric conditions, too. Recently, expanded genotype and phenotype correlations in inherited DI disorders have been described and may better predict the clinical course in affected children and infants. Similarly, newer formulations of synthetic AVP may improve pediatric DI treatment. In contrast to DI, SIADH, characterized by inappropriate AVP secretion, commonly leads to severe hyponatremia. Contemporary methods aid clinicians in distinguishing SIADH from other hyponatremic conditions, particularly cerebral salt wasting. Further research on the efficacy of therapies for pediatric SIADH is needed, although some adult treatments hold promise for pediatrics. Lastly, expansion of home point-of-care sodium testing may transform management of SIADH and DI in children. In this article, we review recent developments in the understanding of pathophysiology, diagnostic workup, and treatment of better outcomes and quality of life for children with these challenging disorders.
Collapse
Affiliation(s)
- Jane E Driano
- School of Medicine, Creighton University, Omaha, Nebraska; and
| | - Aida N Lteif
- Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, Minnesota
| | - Ana L Creo
- Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
19
|
Castle-Kirszbaum M, Kyi M, Wright C, Goldschlager T, Danks RA, Parkin WG. Hyponatraemia and hypernatraemia: Disorders of Water Balance in Neurosurgery. Neurosurg Rev 2021; 44:2433-2458. [PMID: 33389341 DOI: 10.1007/s10143-020-01450-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/26/2020] [Accepted: 11/25/2020] [Indexed: 12/23/2022]
Abstract
Disorders of tonicity, hyponatraemia and hypernatraemia, are common in neurosurgical patients. Tonicity is sensed by the circumventricular organs while the volume state is sensed by the kidney and peripheral baroreceptors; these two signals are integrated in the hypothalamus. Volume is maintained through the renin-angiotensin-aldosterone axis, while tonicity is defended by arginine vasopressin (antidiuretic hormone) and the thirst response. Edelman found that plasma sodium is dependent on the exchangeable sodium, potassium and free-water in the body. Thus, changes in tonicity must be due to disproportionate flux of these species in and out of the body. Sodium concentration may be measured by flame photometry and indirect, or direct, ion-sensitive electrodes. Only the latter method is not affected by changes in plasma composition. Classification of hyponatraemia by the volume state is imprecise. We compare the tonicity of the urine, given by the sodium potassium sum, to that of the plasma to determine the renal response to the dysnatraemia. We may then assess the activity of the renin-angiotensin-aldosterone axis using urinary sodium and fractional excretion of sodium, urate or urea. Together, with clinical context, these help us determine the aetiology of the dysnatraemia. Symptomatic individuals and those with intracranial catastrophes require prompt treatment and vigilant monitoring. Otherwise, in the absence of hypovolaemia, free-water restriction and correction of any reversible causes should be the mainstay of treatment for hyponatraemia. Hypernatraemia should be corrected with free-water, and concurrent disorders of volume should be addressed. Monitoring for overcorrection of hyponatraemia is necessary to avoid osmotic demyelination.
Collapse
Affiliation(s)
| | - Mervyn Kyi
- Department of Endocrinology, Melbourne Health, Melbourne, Australia
| | - Christopher Wright
- Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Tony Goldschlager
- Department of Neurosurgery, Monash Health, Melbourne, Australia.,Department of Surgery, Monash University, Melbourne, Australia
| | - R Andrew Danks
- Department of Neurosurgery, Monash Health, Melbourne, Australia.,Department of Surgery, Monash University, Melbourne, Australia
| | - W Geoffrey Parkin
- Department of Surgery, Monash University, Melbourne, Australia.,Department of Intensive Care, Monash Health, Melbourne, Australia
| |
Collapse
|
20
|
Abstract
Adipsic diabetes insipidus (ADI) is a rare but devastating disorder of water balance with significant associated morbidity and mortality. Most patients develop the disease as a result of hypothalamic destruction from a variety of underlying etiologies. Damage to osmolar-responsive neuroreceptors, primarily within the supraoptic and paraventricular nuclei, results in impaired production and release of arginine vasopressin (AVP). Important regulating circuits of thirst sense and drive are regionally colocalized with AVP centers and therefore are also injured. Patients with central diabetes insipidus with impaired thirst response, defined as ADI, suffer from wide swings of plasma osmolality resulting in repeated hospitalization, numerous associated comorbidities, and significant mortality. Treatment recommendations are based largely on expert advice from case series owing to the rarity of disease prevalence. Acute disease management focuses on fixed dosing of antidiuretic hormone analogues and calculated prescriptions of obligate daily water intake. Long-term care requires patient/family education, frequent reassessment of clinical and biochemical parameters, as well as screening and treatment of comorbidities.
Collapse
Affiliation(s)
- Vallari Kothari
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Zulma Cardona
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Yuval Eisenberg
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| |
Collapse
|
21
|
Abstract
Recent experiments using optogenetic tools facilitate the identification and functional analysis of thirst neurons and vasopressin-producing neurons. Four major advances provide a detailed anatomy and physiology of thirst, taste for water, and arginine-vasopressin (AVP) release: ( a) Thirst and AVP release are regulated by the classical homeostatic, interosensory plasma osmolality negative feedback as well as by novel, exterosensory, anticipatory signals. These anticipatory signals for thirst and vasopressin release concentrate on the same homeostatic neurons and circumventricular organs that monitor the composition of blood. ( b) Acid-sensing taste receptor cells (TRCs) expressing otopetrin 1 on type III presynaptic TRCs on the tongue, which were previously suggested as the sour taste sensors, also mediate taste responses to water. ( c) Dehydration is aversive, and median preoptic nucleus (MnPO) neuron activity is proportional to the intensity of this aversive state. ( d) MnPOGLP1R neurons serve as a central detector that discriminates fluid ingestion from solid ingestion, which promotes acute satiation of thirst through the subfornical organ and other downstream targets.
Collapse
Affiliation(s)
- Daniel G Bichet
- University of Montreal and Nephrology Service, Research Center, Hôpital du Sacré-Coeur de Montreal, Montreal, Quebec H4J 1C5, Canada;
| |
Collapse
|
22
|
Kobayashi S, Tanigawa J, Kondo H, Nabatame S, Maruoka A, Sho H, Tanikawa K, Inui R, Otsuki M, Shimomura I, Ozono K, Hashimoto K. Endocrinological Features of Hartsfield Syndrome in an Adult Patient With a Novel Mutation of FGFR1. J Endocr Soc 2020; 4:bvaa041. [PMID: 32373773 PMCID: PMC7192098 DOI: 10.1210/jendso/bvaa041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 04/02/2020] [Indexed: 11/19/2022] Open
Abstract
Hartsfield syndrome (HS: OMIM 615465) is a rare congenital disease associated with a mutation of the fibroblast growth factor receptor 1 gene (FGFR1) with the main features of holoprosencephaly and ectrodactyly. Patients with HS also present with endocrinological deficits, such as isolated hypogonadotropic hypogonadism and central diabetes insipidus. Although there are several studies on infancy/childhood history, there is no study of infant/childhood/adolescent/young adult HS natural history and endocrinological findings. Here, we report a male patient with HS associated with a novel de novo FGFR1 mutation (c. 1868A > C). The endocrinological profile was evaluated at ages 1 and 31 years. This long-term follow-up study highlights functional changes in the posterior pituitary gland and features of bone metabolism disorder. We also describe the anterior pituitary function. To our knowledge this is the first description of the natural history of an HS patient through birth to young adult age. Although the HS infants reported in the literature develop central diabetes insipidus, little is known about the serial changes in pituitary gland function during growth in HS patients. In this study we describe an adult patient with HS who showed improvement of hypernatremia during early adulthood. In addition, we emphasize the importance of prevention and treatment of osteoporosis in HS.
Collapse
Affiliation(s)
- Sachiko Kobayashi
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Yamadaoka, Suita, Osaka, Japan
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Daini Osaka Police Hospital, Karasugatsuji, Ten-noji, Osaka, Japan
| | - Junpei Tanigawa
- Department of Pediatrics, Graduate School of Medicine, Osaka University, Yamadaoka, Suita, Osaka, Japan
| | - Hidehito Kondo
- Department of Pediatrics, Graduate School of Medicine, Osaka University, Yamadaoka, Suita, Osaka, Japan
- Department of Pediatrics, Kyoto Daiichi Red Cross Hospital, Honmachi, Higashiyama-ku, Kyoto, Japan
| | - Shin Nabatame
- Department of Pediatrics, Graduate School of Medicine, Osaka University, Yamadaoka, Suita, Osaka, Japan
| | - Azusa Maruoka
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Daini Osaka Police Hospital, Karasugatsuji, Ten-noji, Osaka, Japan
| | - Hiroyuki Sho
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Daini Osaka Police Hospital, Karasugatsuji, Ten-noji, Osaka, Japan
| | - Kazuko Tanikawa
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Daini Osaka Police Hospital, Karasugatsuji, Ten-noji, Osaka, Japan
| | - Ryoko Inui
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Daini Osaka Police Hospital, Karasugatsuji, Ten-noji, Osaka, Japan
| | - Michio Otsuki
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Yamadaoka, Suita, Osaka, Japan
| | - Iichiro Shimomura
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Yamadaoka, Suita, Osaka, Japan
| | - Keiichi Ozono
- Department of Pediatrics, Graduate School of Medicine, Osaka University, Yamadaoka, Suita, Osaka, Japan
| | - Kunihiko Hashimoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Daini Osaka Police Hospital, Karasugatsuji, Ten-noji, Osaka, Japan
| |
Collapse
|
23
|
Abstract
Diabetes insipidus (DI) is a disorder characterized by excretion of large amounts of hypotonic urine. Central DI results from a deficiency of the hormone arginine vasopressin (AVP) in the pituitary gland or the hypothalamus, whereas nephrogenic DI results from resistance to AVP in the kidneys. Central and nephrogenic DI are usually acquired, but genetic causes must be evaluated, especially if symptoms occur in early childhood. Central or nephrogenic DI must be differentiated from primary polydipsia, which involves excessive intake of large amounts of water despite normal AVP secretion and action. Primary polydipsia is most common in psychiatric patients and health enthusiasts but the polydipsia in a small subgroup of patients seems to be due to an abnormally low thirst threshold, a condition termed dipsogenic DI. Distinguishing between the different types of DI can be challenging and is done either by a water deprivation test or by hypertonic saline stimulation together with copeptin (or AVP) measurement. Furthermore, a detailed medical history, physical examination and imaging studies are needed to ensure an accurate DI diagnosis. Treatment of DI or primary polydipsia depends on the underlying aetiology and differs in central DI, nephrogenic DI and primary polydipsia.
Collapse
|
24
|
Dalan R, Chin H, Hoe J, Chen A, Tan H, Boehm BO, Chua KS. Adipsic Diabetes Insipidus-The Challenging Combination of Polyuria and Adipsia: A Case Report and Review of Literature. Front Endocrinol (Lausanne) 2019; 10:630. [PMID: 31620086 PMCID: PMC6759785 DOI: 10.3389/fendo.2019.00630] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 08/30/2019] [Indexed: 12/18/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Rinkoo Dalan
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
- Metabolic Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore
- Department of Medicine, Yong Loo School of Medicine, National University of Singapore, Singapore, Singapore
- *Correspondence: Rinkoo Dalan
| | - Hanxin Chin
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jeremy Hoe
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Abel Chen
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Huiling Tan
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Bernhard Otto Boehm
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
- Metabolic Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore
| | - Karen SuiGeok Chua
- Department of Rehabilitation Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| |
Collapse
|
25
|
Nakamura-Utsunomiya A, Hiyama TY, Okada S, Noda M, Kobayashi M. Characteristic clinical features of adipsic hypernatremia patients with subfornical organ-targeting antibody. Clin Pediatr Endocrinol 2017; 26:197-205. [PMID: 29026268 PMCID: PMC5627220 DOI: 10.1297/cpe.26.197] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 04/15/2017] [Indexed: 12/11/2022] Open
Abstract
Adipsic hypernatremia is a rare disease presenting as persistent hypernatremia with disturbance of thirst regulation and hypothalamic dysfunction. As a result of congenital disease, tumors, or inflammation, most cases are accompanied by structural abnormalities in the hypothalamic-pituitary area. While cases with no hypothalamic-pituitary structural lesion have been reported, their etiology has not been elucidated. Recently, we reported three patients with adipsic hypernatremia whose serum-derived immunoglobulin (Ig) specifically reacted with mouse subfornical organ (SFO) tissue. As one of the circumventricular organs (CVOs) that form a sensory interface between the blood and brain, the SFO is a critical site for generating physiological responses to dehydration and hypernatremia. Intravenous injection of the patient's Ig fraction induced hypernatremia in mice, along with inflammation and apoptosis in the SFO. These results support a new autoimmunity-related mechanism for inducing adipsic hypernatremia without demonstrable hypothalamic-pituitary structural lesions. In this review, we aim to highlight the characteristic clinical features of these patients, in addition to etiological mechanisms related to SFO function. These findings may be useful for diagnosing adipsic hypernatremia caused by an autoimmune response to the SFO, and support development of new strategies for prevention and treatment.
Collapse
Affiliation(s)
| | - Takeshi Y Hiyama
- Division of Molecular Neurobiology, National Institute for Basic Biology (NIBB), Aichi, Japan.,School of Life Science, SOKENDAI (The Graduate University for Advanced Studies), Aichi, Japan
| | - Satoshi Okada
- Department of Pediatrics, Hiroshima University Hospital, Hiroshima, Japan
| | - Masaharu Noda
- Division of Molecular Neurobiology, National Institute for Basic Biology (NIBB), Aichi, Japan.,School of Life Science, SOKENDAI (The Graduate University for Advanced Studies), Aichi, Japan
| | - Masao Kobayashi
- Department of Pediatrics, Hiroshima University Hospital, Hiroshima, Japan
| |
Collapse
|
26
|
Hiyama TY, Noda M. Sodium sensing in the subfornical organ and body-fluid homeostasis. Neurosci Res 2016; 113:1-11. [PMID: 27521454 DOI: 10.1016/j.neures.2016.07.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 07/22/2016] [Accepted: 07/28/2016] [Indexed: 01/28/2023]
Abstract
The brain monitors conditions of body fluids and levels of circulating neuroactive factors to maintain the systemic homeostasis. Unlike most regions in the brain, circumventricular organs (CVOs) lack the blood-brain barrier, and serve as the sensing center. Among the CVOs, the subfornical organ (SFO) is the sensing site of Na+ levels in body fluids to control water and salt intake. The SFO harbors neuronal cell bodies with a variety of hormone receptors and innervates many brain loci. In addition, the SFO harbors specialized glial cells (astrocytes and ependymal cells) expressing Nax, a Na+-level-sensitive sodium channel. These glial cells wrap a specific population of neurons with their processes, and control the firing activities of the neurons by gliotransmitters, such as lactate and epoxyeicosatrienoic acids (EETs), relevant to water/salt-intake behaviors. Recent advances in the understanding of physiological functions of the SFO are reviewed herein with a focus on the Na+-sensing mechanism by Nax.
Collapse
Affiliation(s)
- Takeshi Y Hiyama
- Division of Molecular Neurobiology, National Institute for Basic Biology, and School of Life Science, SOKENDAI (The Graduate University for Advanced Studies), Okazaki, Aichi 444-8787, Japan.
| | - Masaharu Noda
- Division of Molecular Neurobiology, National Institute for Basic Biology, and School of Life Science, SOKENDAI (The Graduate University for Advanced Studies), Okazaki, Aichi 444-8787, Japan
| |
Collapse
|