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Henriques AR, M Lopes M, Robalo B, Pereira C, Sampaio MDL. A Rare Case of Central Diabetes Insipidus in a Pediatric Patient. ACTA MEDICA PORT 2024; 37:577-578. [PMID: 38950616 DOI: 10.20344/amp.21113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 05/31/2024] [Indexed: 07/03/2024]
Affiliation(s)
- Ana Raquel Henriques
- Unidade de Endocrinologia Pediátrica. Serviço de Pediatria Médica. Departamento de Pediatria. Hospital de Santa Maria. Unidade Local de Saúde de Santa Maria. Lisboa. Portugal
| | - Miguel M Lopes
- Unidade de Endocrinologia Pediátrica. Serviço de Pediatria Médica. Departamento de Pediatria. Hospital de Santa Maria. Unidade Local de Saúde de Santa Maria. Lisboa. Portugal
| | - Brígida Robalo
- Unidade de Endocrinologia Pediátrica. Serviço de Pediatria Médica. Departamento de Pediatria. Hospital de Santa Maria. Unidade Local de Saúde de Santa Maria. Lisboa. Portugal
| | - Carla Pereira
- Unidade de Endocrinologia Pediátrica. Serviço de Pediatria Médica. Departamento de Pediatria. Hospital de Santa Maria. Unidade Local de Saúde de Santa Maria. Lisboa. Portugal
| | - Maria de Lurdes Sampaio
- Unidade de Endocrinologia Pediátrica. Serviço de Pediatria Médica. Departamento de Pediatria. Hospital de Santa Maria. Unidade Local de Saúde de Santa Maria. Lisboa. Portugal
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Abstract
OBJECTIVE Hypophysitis is considered a rare inflammatory disease of the pituitary gland. For a long time, primary autoimmune hypophysitis has stood out as the most relevant type of hypophysitis. However, with the advent of immunotherapy for the treatment of malignancies and identification of hypophysitis as an immune-related adverse event, hypophysitis has garnered increasing interest and recognition. Therefore, awareness, early recognition, and appropriate management are becoming important as the indication for immunomodulatory therapies broaden. METHODS In this review, we discuss the epidemiology, diagnosis, and treatment of hypophysitis with a focus on recent data and highlight subtypes of particular interest while recognizing the gaps in knowledge that remain. RESULTS Regardless of cause, symptoms and signs of hypophysitis may be related to mass effect (headache and visual disturbance) and hormonal disruption that warrant prompt evaluation. In the vast majority of cases, a diagnosis of hypophysitis can be made presumptively in the appropriate clinical context with radiologic findings consistent with hypophysitis and after the exclusion of other causes. CONCLUSION Although subtle differences currently exist in management and outcome expectations between primary and secondary causes of hypophysitis, universally, treatment is aimed at symptom management and hormonal replacement therapy.
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Donegan D, Saeed Z, Delivanis DA, Murad MH, Honegger J, Amereller F, Oguz SH, Erickson D, Bancos I. Outcomes of Initial Management Strategies in Patients With Autoimmune Lymphocytic Hypophysitis: A Systematic Review and Meta-analysis. J Clin Endocrinol Metab 2022; 107:1170-1190. [PMID: 35137155 PMCID: PMC8947799 DOI: 10.1210/clinem/dgab839] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Indexed: 02/08/2023]
Abstract
CONTEXT Lymphocytic hypophysitis (LyHy) is characterized by inflammation of the pituitary and or neuroinfundibulum and is uncommon. Treatment options include observation, high-dose glucocorticoids (HD-GCs) or surgery. Optimal first-line management strategy, however, remains unknown. OBJECTIVE This work aimed to assess response to first-line treatment options (observation, HD-GCs, or surgery) of clinically relevant outcomes (symptomatic, hormonal, and radiographic improvement) among patients with LyHy. METHODS A systematic review was conducted in 6 databases through 2020. Meta-analysis was conducted when feasible using a random-effects model. RESULTS We included 33 studies reporting on 591 patients (423 women, 72%) with LyHy. Improvement/resolution of anterior pituitary dysfunction was highest when HD-GCs was first-line treatment. Surgery was associated with the greatest proportion of patients who had regression on imaging. Subgroup analysis comparing HD-GCs to observation showed the odds of anterior pituitary hormone recovery (OR 3.41; 95% CI, 1.68-6.94) or radiographic regression (OR 3.13; 95% CI, 1.54-6.36) were higher with HD-GCs, but so was the need for additional forms of treatment (OR 4.37; 95% CI, 1.70-11.22). No statistically significant difference was seen in recovery of diabetes insipidus (OR 0.9; 95% CI, 0.26-3.10). Certainty in these estimates was very low. CONCLUSION Observation and use of HD-GCs both are successful first-line management strategies in LyHy. Although use of HD-GCs was associated with increased recovery of anterior pituitary hormone deficit, it also was associated with greater likelihood of additional treatment after withdrawal. Optimal dosing and duration of HD-GCs remains unknown.
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Affiliation(s)
- Diane Donegan
- Division of Endocrinology, Diabetes and Metabolism, Indiana University School of Medicine, Indianapolis, Indiana 46206, USA
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota 55905, USA
- Correspondence: D. Donegan, MB, BCh, BAO, Division of Endocrinology, Diabetes and Metabolism, Indiana University School of Medicine, 1120 W. Michigan St, CL 459, Indianapolis, IN 46206, USA.
| | - Zeb Saeed
- Division of Endocrinology, Diabetes and Metabolism, Indiana University School of Medicine, Indianapolis, Indiana 46206, USA
| | - Danae A Delivanis
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota 55905, USA
| | | | - Juergen Honegger
- Department of Neurosurgery, University of Tübingen, 72076 Tübingen, Germany
| | - Felix Amereller
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, 80336 Munich, Germany
| | - Seda Hanife Oguz
- Department of Endocrinology and Metabolism, Hacettepe University Medical School, 06230 Ankara, Turkey
| | - Dana Erickson
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota 55905, USA
- I. Bancos, MD, Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, MN 55905, USA.
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Abstract
Most cases of acquired central diabetes insipidus are caused by destruction of the neurohypophysis by: 1) anatomic lesions that destroy the vasopressin neurons by pressure or infiltration, 2) damage to the vasopressin neurons by surgery or head trauma, and 3) autoimmune destruction of the vasopressin neurons. Because the vasopressin neurons are located in the hypothalamus, lesions confined to the sella turcica generally do not cause diabetes insipidus because the posterior pituitary is simply the site of the axon terminals that secrete vasopressin into the bloodstream. In addition, the capacity of the neurohypophysis to synthesize vasopressin is greatly in excess of the body's needs, and destruction of 80-90% of the hypothalamic vasopressin neurons is required to produce diabetes insipidus. As a result, even large lesions in the sellar and suprasellar area generally are not associated with impaired water homeostasis until they are surgically resected. Regardless of the etiology of central diabetes insipidus, deficient or absent vasopressin secretion causes impaired urine concentration with resultant polyuria. In most cases, secondary polydipsia is able to maintain water homeostasis at the expense of frequent thirst and drinking. However, destruction of the osmoreceptors in the anterior hypothalamus that regulate vasopressin neuronal activity causes a loss of thirst as well as vasopressin section, leading to severe chronic dehydration and hyperosmolality. Vasopressin deficiency also leads to down-regulation of the synthesis of aquaporin-2 water channels in the kidney collecting duct principal cells, causing a secondary nephrogenic diabetes insipidus. As a result, several days of vasopressin administration are required to achieve maximal urine concentration in patients with CDI. Consequently, the presentation of patients with central diabetes insipidus can vary greatly, depending on the size and location of the lesion, the magnitude of trauma to the neurohypophysis, the degree of destruction of the vasopressin neurons, and the presence of other hormonal deficits from damage to the anterior pituitary.
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MESH Headings
- Aquaporin 2/metabolism
- Brain Injuries, Traumatic/complications
- Brain Injuries, Traumatic/diagnosis
- Brain Injuries, Traumatic/epidemiology
- Brain Injuries, Traumatic/therapy
- Diabetes Insipidus, Nephrogenic/etiology
- Diabetes Insipidus, Nephrogenic/metabolism
- Diabetes Insipidus, Neurogenic/diagnosis
- Diabetes Insipidus, Neurogenic/epidemiology
- Diabetes Insipidus, Neurogenic/etiology
- Diabetes Insipidus, Neurogenic/therapy
- Homeostasis/physiology
- Humans
- Neurophysins/physiology
- Pituitary Diseases/complications
- Pituitary Diseases/diagnosis
- Pituitary Diseases/epidemiology
- Pituitary Diseases/therapy
- Pituitary Gland, Posterior/pathology
- Polydipsia/diagnosis
- Polydipsia/epidemiology
- Polydipsia/etiology
- Polydipsia/therapy
- Polyuria/diagnosis
- Polyuria/epidemiology
- Polyuria/etiology
- Polyuria/therapy
- Protein Precursors/physiology
- Vasopressins/physiology
- Water-Electrolyte Balance/physiology
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Corredor Andrés B, Muñoz Calvo MT, López Pino MÁ, Márquez Rivera M, Travieso Suárez L, Pozo Román J, Argente J. Thickening of the pituitary stalk in children and adolescents with central diabetes insipidus: Causes and consequences. An Pediatr (Barc) 2019. [DOI: 10.1016/j.anpede.2018.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Doknic M, Miljic D, Pekic S, Stojanovic M, Savic D, Manojlovic-Gacic E, Milenkovic T, Zdravkovic V, Jesic M, Damjanovic D, Lavrnic S, Soldatovic I, Djukic A, Petakov M. Single center study of 53 consecutive patients with pituitary stalk lesions. Pituitary 2018; 21:605-614. [PMID: 30276501 DOI: 10.1007/s11102-018-0914-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The etiological spectrum of pituitary stalk lesions (PSL) is wide and yet specific compared to the other diseases of the sellar and suprasellar region. Because of the pituitary stalk's (PS) critical location and role, biopsies of these lesions are rarely performed, and their underlying pathology is often a conundrum for clinicians. A pituitary MRI in association with a clinical context can facilitate their diagnosis. AIM To present the various causes of PSL-their clinical, hormonal, histopathological, and MRI characteristics in order to gain better insight into this pathology. METHOD A retrospective observational study consisting of 53 consecutive patients with PSL of the mean age 32 ± 4.2 years (range 6-67), conducted at the Department for Neuroendocrinology, Clinical Center of Serbia 2010-2018. RESULTS Congenital malformations were the most common cause of PSL in 25 of 53 patients (47.1%), followed by inflammatory (9/53; 16.9%) and neoplastic lesions (9/53; 16.9%). The exact cause of PSL was established in 31 (58.4%) patients, of whom 23 were with congenital PS abnormalities and 8 with histopathology of PSL (7 neoplastic and 1 Langerhans Cell Hystiocytosis). A probable diagnosis of PSL was stated in 12 patients (22.6%): 6 with lymphocytic panhypophysitis, while Rathke cleft cyst, tuberculosis, dissemination of malignancy in PS were each diagnosed in 2 patients. In 10 patients (18.8%), the etiology of PSL remained unknown. CONCLUSION Due to the inability of establishing an exact diagnosis, the management and prognosis of PSL are difficult in many patients. By presenting a wide array of causes implicated in this condition, we believe that our study can aid clinicians in the challenging cases of this pathology.
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Affiliation(s)
- Mirjana Doknic
- Neuroendocrine Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Dr Subotica 13, Belgrade, 11000, Serbia.
- School of Medicine, University of Belgrade, Belgrade, Serbia.
| | - Dragana Miljic
- Neuroendocrine Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Dr Subotica 13, Belgrade, 11000, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Sandra Pekic
- Neuroendocrine Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Dr Subotica 13, Belgrade, 11000, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marko Stojanovic
- Neuroendocrine Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Dr Subotica 13, Belgrade, 11000, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dragan Savic
- Clinic for Neurosurgery, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Emilija Manojlovic-Gacic
- Institute of Pathology, School of Medicine, University of Belgrade, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Tatjana Milenkovic
- Mother and Child Health Care Institute of Serbia "Dr Vukan Cupic", Belgrade, Serbia
| | - Vera Zdravkovic
- University Children's Clinic, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Maja Jesic
- University Children's Clinic, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dusan Damjanovic
- Center for Radiology Imaging - Magnetic Resonance and Gamma Knife, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Slobodan Lavrnic
- Center for Radiology Imaging - Magnetic Resonance and Gamma Knife, Clinical Center of Serbia, Belgrade, Serbia
| | - Ivan Soldatovic
- Institute of Medical Statistics and Informatics, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Aleksandar Djukic
- Center for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Kragujevac, Kragujevac, Serbia
| | - Milan Petakov
- Neuroendocrine Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Dr Subotica 13, Belgrade, 11000, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
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Corredor Andrés B, Muñoz Calvo MT, López Pino MÁ, Márquez Rivera M, Travieso Suárez L, Pozo Román J, Argente J. [Thickening of the pituitary stalk in children and adolescents with central diabetes insipidus: Causes and consequences]. An Pediatr (Barc) 2018; 90:293-300. [PMID: 29895434 DOI: 10.1016/j.anpedi.2018.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 04/30/2018] [Accepted: 05/02/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Central diabetes insipidus (CDI) is a rare disorder in children. The aetiology of CDI in childhood is heterogeneous. The aim of this study is to illustrate the importance of a careful clinical and neuro-radiological follow-up of the pituitary and hypothalamus region in order to identify the aetiology and the development of associated hormonal deficiencies. METHODS Clinical and auxological variables of 15 children diagnosed with CDI were retrospectively analysed in a paediatric hospital. Evaluations of adenohypophyseal function and cranial MRI were performed periodically. RESULTS The mean age at diagnosis of CDI was 9.6 years (range: 1.32-15.9). The aetiological diagnosis could be established initially in 9 of the 15 patients, as 7 with a germinoma and 2 with a histiocytosis. After a mean follow-up of 5.5 years (range: 1.6-11.8), the number of idiopathic cases was reduced by half. At the end of the follow-up, the aetiological diagnoses were: 9 germinoma (60%), 3 histiocytosis (20%), and 3 idiopathic CDI (20%). There is a statistically significant association between stalk thickening and tumour aetiology. At least one adenohypophyseal hormonal deficiency was found in 67% of cases, with the majority developing in the first two years of follow-up. Growth hormone deficiency (60%) was the most prevalent. CONCLUSION The follow-up of CDI should include hormone evaluation with special attention, due to its frequency, to GH deficiency. In addition, a biannual MRI in an idiopathic CDI should be performed, at least during the first 2-3 years after diagnosis, as 50% of them were diagnosed with a germinoma or histiocytosis during this period.
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Affiliation(s)
- Beatriz Corredor Andrés
- Servicio de Pediatría y Endocrinología, Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - María Teresa Muñoz Calvo
- Servicio de Pediatría y Endocrinología, Hospital Infantil Universitario Niño Jesús, Madrid, España; Departamento de Pediatría, Universidad Autónoma de Madrid, Madrid, España; CIBER Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, Madrid, España..
| | - Miguel Ángel López Pino
- Servicio de Radiología Pediátrica, Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - María Márquez Rivera
- Servicio de Pediatría y Endocrinología, Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - Lourdes Travieso Suárez
- Servicio de Pediatría y Endocrinología, Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - Jesús Pozo Román
- Servicio de Pediatría y Endocrinología, Hospital Infantil Universitario Niño Jesús, Madrid, España; Departamento de Pediatría, Universidad Autónoma de Madrid, Madrid, España; CIBER Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, Madrid, España
| | - Jesús Argente
- Servicio de Pediatría y Endocrinología, Hospital Infantil Universitario Niño Jesús, Madrid, España; Departamento de Pediatría, Universidad Autónoma de Madrid, Madrid, España; CIBER Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, Madrid, España.; IMDEA Instituto de Alimentación, CEI UAM + CSIC, Madrid, España
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