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Dyrka K, Dzialach L, Niedziela M, Jonczyk-Potoczna K, Derwich K, Obara-Moszynska M. Central Diabetes Insipidus in Children as a Diagnostic Challenge. Clin Pediatr (Phila) 2023:99228231202607. [PMID: 37798950 DOI: 10.1177/00099228231202607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Central diabetes insipidus (CDI) is a disorder in the pediatric population resulting from antidiuretic hormone deficiency. The excessive production of dilute urine characterizes it and manifests with polyuria, nocturia, and polydipsia. The diagnostics of CDI is often challenging, especially concerning the underlying condition of the disease. This article highlights the diverse clinical presentation of children with CDI and diagnostic difficulties among patients with polyuria and polydipsia. The article also reviews the etiology, symptoms, diagnostic workup, and management of CDI. We present 4 pediatric patients (aged 3-13.5 years) diagnosed with CDI of different etiology: 1 due to septo-optic dysplasia/optic nerve hypoplasia and 3 due to acquired processes such as Langerhans cell histiocytosis and germ cell tumor in 2 patients. Central diabetes insipidus was the first manifestation of a tumor or granuloma in all presented patients with acquired pathology. The patients sometimes need long-term follow-up to establish the proper final diagnosis.
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Affiliation(s)
- Kamil Dyrka
- Department of Pediatric Endocrinology and Rheumatology, Institute of Pediatrics, Poznan University of Medical Sciences, Poznan, Poland
| | - Lukasz Dzialach
- Department of Pediatric Endocrinology and Rheumatology, Institute of Pediatrics, Poznan University of Medical Sciences, Poznan, Poland
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Marek Niedziela
- Department of Pediatric Endocrinology and Rheumatology, Institute of Pediatrics, Poznan University of Medical Sciences, Poznan, Poland
| | - Katarzyna Jonczyk-Potoczna
- Department of Pediatric Radiology, Institute of Pediatrics, Poznan University of Medical Sciences, Poznan, Poland
| | - Katarzyna Derwich
- Department of Pediatric Oncology, Hematology and Transplantology, Institute of Pediatrics, Poznan University of Medical Sciences, Poznan, Poland
| | - Monika Obara-Moszynska
- Department of Pediatric Endocrinology and Rheumatology, Institute of Pediatrics, Poznan University of Medical Sciences, Poznan, Poland
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Gasimova E, Berberoğlu M, Özsu E, Aycan Z, Uyanık R, Bilici E, Ceran A, Şiklar Z. Evaluation of the etiological and clinical characteristics of pediatric central diabetes insipidus. J Pediatr Endocrinol Metab 2022; 35:1089-1096. [PMID: 35822703 DOI: 10.1515/jpem-2022-0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/20/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Central diabetes insipidus (CDI) is a rare but important disease of varying etiology that poses challenges in diagnosis and follow-up. Identifying diagnostic difficulties in patients with CDI will help ensure an optimal approach to their management and follow-up. This study aimed to characterize the clinical and etiological characteristics of CDI in pediatric patients. METHODS We analyzed the admission and follow-up data of CDI patients aged 0-18 years who were followed in our center between 2010 and 2019. RESULTS The study included 56 patients with a mean age at diagnosis of 7.92 ± 5.11 years and symptom duration of 8.65 ± 21.3 months. The patients were grouped by etiology into those with organic causes, such as structural anomalies, tumors, and trauma (group 1, n=41) and other causes (group 2, n=15). The prevalence of idiopathic CDI was 16%. At least one pituitary hormone deficiency was detected in 60.7%, the most common being thyroid stimulating hormone deficiency. Patients in group 1 had a higher mean age at diagnosis, shorter symptom duration, and higher frequency of other pituitary hormone deficiencies compared to group 2. Additionally, germinoma was detected 1 year subsequent to normal MRI findings at diagnosis and another patient was diagnosed with Langerhans cell histiocytosis (LCH) 5 years after diagnosis. All patients responded well to replacement therapies, but two patients with germinoma died during follow-up. CONCLUSIONS In the pediatric age group, intracranial organic pathologies are an important etiology of CDI, and despite a short symptomatic period, determining the cause may be challenging and prolonged. Patients presenting at a young age with a long history of symptoms and no other pituitary hormone deficiency are unlikely to have organic CDI. However, organic causes such as LCH should be evaluated at all ages. Patients with idiopathic disease are candidates for further etiological studies, and repeated cranial imaging is important during follow-up.
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Affiliation(s)
- Elnare Gasimova
- Department of Pediatrics Balkiraz Mahallesi, Ankara Univesity School of Medicine, Mamak, Ankara, Turkey
| | - Merih Berberoğlu
- Department of Pediatric Endocrinology and Diabetes, Ankara Univesity School of Medicine, Mamak, Ankara, Turkey
| | - Elif Özsu
- Department of Pediatric Endocrinology and Diabetes, Ankara Univesity School of Medicine, Mamak, Ankara, Turkey
| | - Zehra Aycan
- Department of Pediatric Endocrinology and Diabetes, Ankara Univesity School of Medicine, Mamak, Ankara, Turkey
| | - Rukiye Uyanık
- Department of Pediatric Endocrinology and Diabetes, Ankara Univesity School of Medicine, Mamak, Ankara, Turkey
| | - Esra Bilici
- Department of Pediatric Endocrinology and Diabetes, Ankara Univesity School of Medicine, Mamak, Ankara, Turkey
| | - Ayşegül Ceran
- Department of Pediatric Endocrinology and Diabetes, Ankara Univesity School of Medicine, Mamak, Ankara, Turkey
| | - Zeynep Şiklar
- Department of Pediatric Endocrinology and Diabetes, Ankara Univesity School of Medicine, Mamak, Ankara, Turkey
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Omar MA, Kewan HF, Kandeel H, Shehadeh AM. Coexisting Cerebral Salt Wasting Syndrome and Central Diabetes Insipidus in a Patient with Posterior Cerebrovascular Infarction: A Case Report. DUBAI MEDICAL JOURNAL 2021. [DOI: 10.1159/000517799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
<b><i>Background:</i></b> Disorders of sodium balance are common in critically ill neurologic patients. However, the coexisting of cerebral salt wasting syndrome (CSW) and central diabetes insipidus (CDI) in such patients is rare. Early recognition of such conditions is challenging, thus making the prognosis ominous. <b><i>Case Presentation:</i></b> A 50-year-old male patient presented with acute posterior cerebrovascular infarction complicated by several attacks of disturbed sodium homeostasis. The first attack manifested as hypernatremia (up to 161 mmol/L) and polyuria with high urine sodium (188 mmol/L) could only be explained by CSW on top of CDI. Especially the patient was not receiving any hyperosmolar or sodium-containing fluids. Serum sodium was corrected by desmopressin acetate. Later, the patient developed 2 attacks of hyponatremia (down to 119 mmol/L) diagnosed as CSW that was treated with fludrocortisone. Finally, he developed hypernatremia (up to 165 mmol/L) diagnosed as CDI and was treated with desmopressin acetate. <b><i>Conclusion:</i></b> Sodium hemostasis disorders require full consideration of serum electrolytes, intravascular volume state, and urine electrolytes in view of the clinical condition. Early diagnosis and administration of the proper treatment are the cornerstones of successful management.
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Farrell TP, Adams NC, Looby S. Neuroimaging of central diabetes insipidus. HANDBOOK OF CLINICAL NEUROLOGY 2021; 181:207-237. [PMID: 34238459 DOI: 10.1016/b978-0-12-820683-6.00016-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Central diabetes insipidus (CDI) occurs secondary to deficient synthesis or secretion of arginine vasopressin peptide from the hypothalamo-neurohypophyseal system (HNS). It is characterized by polydipsia and polyuria (urine output >30mL/kg/day in adults and >2l/m2/24h in children) of dilute urine (<250mOsm/L). It can result from any pathology affecting one or more components of the HNS including the hypothalamic osmoreceptors, supraoptic or paraventricular nuclei, and median eminence of the hypothalamus, infundibulum, stalk or the posterior pituitary gland. MRI is the imaging modality of choice for evaluation of the hypothalamic-pituitary axis (HPA), and a dedicated pituitary or sella protocol is essential. CT can provide complimentary diagnostic information and is also of value when MRI is contraindicated. The most common causes are benign or malignant neoplasia of the HPA (25%), surgery (20%), and head trauma (16%). No cause is identified in up to 30% of cases, classified as idiopathic CDI. Knowledge of the anatomy and physiology of the HNS is crucial when evaluating a patient with CDI. Establishing the etiology of CDI with MRI in combination with clinical and biochemical assessment facilitates appropriate targeted treatment. This chapter illustrates the wide variety of causes and imaging correlates of CDI on neuroimaging, discusses the optimal imaging protocols, and revises the detailed neuroanatomy required to interpret these studies.
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Affiliation(s)
- Terence Patrick Farrell
- Division of Neuroradiology, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Niamh Catherine Adams
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Seamus Looby
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
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Saito T, Sugai K, Takahashi A, Ikegaya N, Nakagawa E, Sasaki M, Iwasaki M, Otsuki T. Transient water-electrolyte disturbance after hemispherotomy in young infants with epileptic encephalopathy. Childs Nerv Syst 2020; 36:1043-1048. [PMID: 31845027 DOI: 10.1007/s00381-019-04452-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 11/26/2019] [Indexed: 01/16/2023]
Abstract
PURPOSE This study aimed to elucidate the clinical features of water-electrolyte disturbance (WED) as a sequela of hemispherotomy. METHODS We performed a retrospective chart review to identify the clinical features of diabetes insipidus (DI) as a complication in < 12-month-old patients who underwent hemispherectomy or hemispherotomy for severe epilepsy between 2007 and 2018. Central DI was diagnosed if a patient developed polyuria (urine output > 5 mL/kg/h), abnormally high serum osmolality (> 300 mOsm/kg), high serum sodium level (> 150 mEq/L), either abnormally low urine specific gravity (< 1.005) or low urine osmolality (< 300 mOsm/kg) or both, and effective control of polyuria with arginine vasopressin (AVP). The clinical course of post-hemispherotomy WED, complications other than WED, and seizure outcomes were analyzed. RESULTS The review identified that 3 of 23 infants developed WED. All patients developed polyuria within 2 days after surgery, with high serum osmolality and hypotonic urine; AVP was effective in treating these symptoms. The clinical course was compatible with central DI. Two patients subsequently developed hyponatremia in a biphasic or triphasic manner. All patients had multiple seizures that were probably related to WED. Two patients developed asymptomatic cerebral sinovenous thrombosis, possibly because of the surgical procedure and dehydration; anticoagulant treatment was provided. All patients were treated for WED for up to 2 months and had no residual pituitary dysfunction. CONCLUSION Systemic complications other than intracranial ones can occur in patients who have undergone hemispherotomy. Perioperative systemic management of young infants undergoing this procedure should include careful water and electrolyte balance monitoring.
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Affiliation(s)
- Takashi Saito
- Department of Child Neurology, National Center of Neurology and Psychiatry (NCNP), 4-1-1 Ogawa higashi-cho, Kodaira, Tokyo, 187-8551, Japan.
| | - Kenji Sugai
- Department of Child Neurology, National Center of Neurology and Psychiatry (NCNP), 4-1-1 Ogawa higashi-cho, Kodaira, Tokyo, 187-8551, Japan
| | - Akio Takahashi
- Department of Neurosurgery, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Naoki Ikegaya
- Department of Neurosurgery, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Eiji Nakagawa
- Department of Child Neurology, National Center of Neurology and Psychiatry (NCNP), 4-1-1 Ogawa higashi-cho, Kodaira, Tokyo, 187-8551, Japan
| | - Masayuki Sasaki
- Department of Child Neurology, National Center of Neurology and Psychiatry (NCNP), 4-1-1 Ogawa higashi-cho, Kodaira, Tokyo, 187-8551, Japan
| | - Masaki Iwasaki
- Department of Neurosurgery, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Taisuke Otsuki
- Department of Neurosurgery, National Center of Neurology and Psychiatry, Tokyo, Japan
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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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Neuroimaging of central diabetes insipidus—when, how and findings. Neuroradiology 2018; 60:995-1012. [DOI: 10.1007/s00234-018-2072-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 07/30/2018] [Indexed: 12/19/2022]
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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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Haddad NG, Nabhan ZM, Eugster EA. INCIDENCE OF CENTRAL DIABETES INSIPIDUS IN CHILDREN PRESENTING WITH POLYDIPSIA AND POLYURIA. Endocr Pract 2016; 22:1383-1386. [PMID: 27540876 DOI: 10.4158/ep161333.or] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Polydipsia and polyuria are common reasons for referral to the Pediatric Endocrine clinic. In the absence of hyperglycemia, diabetes insipidus (DI) should be considered. The objectives of the study were to determine the prevalence of central DI (CDI) in a group of children presenting for evaluation of polydipsia and polyuria, and to determine if predictive features were present in patients in whom the diagnosis of DI was made. METHODS The study was a retrospective chart review of children presenting to the endocrine clinic with complaints of polydipsia and polyuria over a 5-year period. RESULTS The charts of 41 patients (mean age 4.9 ± 3.7 years, 28 males) were reviewed. CDI was diagnosed in 8 (20%) children based on abnormal water deprivation test (WDT) results. All but one patient had abnormal magnetic resonance imaging (MRI) findings, the most common being pituitary stalk thickening. Children with DI were older (7.86 ± 4.40 vs. 4.18 ± 3.20 years, P = .01) and had a higher propensity for cold beverages intake and unusual water-seeking behaviors compared to those without DI. Baseline WDT also revealed higher serum sodium (Na) and osmolality. CONCLUSION The incidence of CDI in children presenting with polydipsia and polyuria is low. Factors associated with higher likelihood of pathology include older age, propensity for cold beverage intake, and higher baseline serum Na and osmolality on a WDT. ABBREVIATIONS BMI = body mass index CDI = central diabetes insipidus DI = diabetes insipidus Na = sodium WDT = water deprivation test.
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Liu W, Wang L, Liu M, Li G. Pituitary Morphology and Function in 43 Children with Central Diabetes Insipidus. Int J Endocrinol 2016; 2016:6365830. [PMID: 27118970 PMCID: PMC4828552 DOI: 10.1155/2016/6365830] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 01/25/2016] [Accepted: 02/28/2016] [Indexed: 12/28/2022] Open
Abstract
Objective. In pediatric central diabetes insipidus (CDI), etiology diagnosis and pituitary function monitoring are usually delayed. This study aimed to illustrate the importance of regular follow-up and pituitary function monitoring in pediatric CDI. Methods. The clinical, hormonal, and neuroradiological characteristics of children with CDI at diagnosis and during 1.5-2-year follow-up were collected and analyzed. Results. The study included 43 CDI patients. The mean interval between initial manifestation and diagnosis was 22.29 ± 3.67 months (range: 2-108 months). The most common complaint was polyuria/polydipsia. Causes included Langerhans cell histiocytosis, germinoma, and craniopharyngioma in 2, 5, and 4 patients; the remaining were idiopathic. No significant changes were found during the 1.5-2 years after CDI diagnosis. Twenty-three of the 43 cases (53.5%) had ≥1 anterior pituitary hormone deficiency. Isolated growth hormone deficiency was the most frequent abnormality (37.5%) and was not associated with pituitary stalk diameter. Multiple pituitary hormone deficiencies were found in 8 cases with pituitary stalk diameter > 4.5 mm. Conclusion. Diagnosis of CDI is usually delayed. CDI with a pituitary stalk diameter > 4.5 mm carries a higher risk of multiple pituitary hormone deficiencies. Long-term MRI and pituitary function follow-ups are necessary for children with idiopathic CDI.
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Affiliation(s)
- Wendong Liu
- Department of Pediatrics, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China
- Department of Pediatrics, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao 266011, China
| | - Limin Wang
- Department of Pediatrics, Qingdao Municipal Hospital Affiliated to Qingdao University, Qingdao 266011, China
| | - Minghua Liu
- Department of Child Health Care, Shandong Maternal and Child Health Care Hospital, Jinan 250021, China
| | - Guimei Li
- Department of Pediatrics, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China
- *Guimei Li:
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Wu X, Zhou X, Gao L, Wu X, Fei L, Mao Y, Hu J, Zhou L. Diagnosis and Management of Combined Central Diabetes Insipidus and Cerebral Salt Wasting Syndrome After Traumatic Brain Injury. World Neurosurg 2015; 88:483-487. [PMID: 26485413 DOI: 10.1016/j.wneu.2015.10.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 10/09/2015] [Accepted: 10/12/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Combined central diabetes insipidus and cerebral salt wasting syndrome after traumatic brain injury (TBI) is rare, is characterized by massive polyuria leading to severe water and electrolyte disturbances, and usually is associated with very high mortality mainly as a result of delayed diagnosis and improper management. METHODS We retrospectively reviewed the clinical presentation, management, and outcomes of 11 patients who developed combined central diabetes insipidus and cerebral salt wasting syndrome after traumatic brain injury to define distinctive features for timely diagnosis and proper management. RESULTS The most typical clinical presentation was massive polyuria (10,000 mL/24 hours or >1000 mL/hour) refractory to vasopressin alone but responsive to vasopressin plus cortisone acetate. Other characteristic presentations included low central venous pressure, high brain natriuretic peptide precursor level without cardiac dysfunction, high 24-hour urine sodium excretion and hypovolemia, and much higher urine than serum osmolarity; normal serum sodium level and urine specific gravity can also be present. Timely and adequate infusion of sodium chloride was key in treatment. Of 11 patients, 5 had a good prognosis 3 months later (Extended Glasgow Outcome Scale score ≥6), 1 had an Extended Glasgow Outcome Scale score of 4, 2 died in the hospital of brain hernia, and 3 developed a vegetative state. CONCLUSIONS For combined diabetes insipidus and cerebral salt wasting syndrome after traumatic brain injury, massive polyuria is a major typical presentation, and intensive monitoring of fluid and sodium status is key for timely diagnosis. To achieve a favorable outcome, proper sodium chloride supplementation and cortisone acetate and vasopressin coadministration are key.
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Affiliation(s)
- Xuehai Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaolan Zhou
- Worldwide Medical Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Liang Gao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Xing Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Li Fei
- Department of Neurosurgery, Jinshan Hospital, Fudan University, Shanghai, China
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China.
| | - Liangfu Zhou
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
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Di Iorgi N, Morana G, Napoli F, Allegri AEM, Rossi A, Maghnie M. Management of diabetes insipidus and adipsia in the child. Best Pract Res Clin Endocrinol Metab 2015; 29:415-36. [PMID: 26051300 DOI: 10.1016/j.beem.2015.04.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Central diabetes insipidus (CDI) is a complex and heterogeneous clinical syndrome affecting the hypothalamic-neurohypophyseal network and water balance. A recent national surveillance in Denmark showed a prevalence rate of twenty-three CDI patients per 100,000 inhabitants in five years. The differential diagnosis between several presenting conditions with polyuria and polydipsia is puzzling, and the etiological diagnosis of CDI remains a challenge before the identification of an underlying cause. For clinical practice, a timely diagnosis for initiating specific treatment in order to avoid central nervous system damage, additional pituitary defects and the risk of dissemination of germ cell tumor is advisable. Proper etiological diagnosis can be achieved via a series of steps that start with careful clinical observation of several signs and endocrine symptoms and then progress to more sophisticated imaging tools. This review summarizes the best practice and approach for the diagnosis and treatment of patients with CDI.
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Affiliation(s)
- Natascia Di Iorgi
- Department of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Giovanni Morana
- Department of Pediatric Neuroradiology, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Flavia Napoli
- Department of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | | | - Andrea Rossi
- Department of Pediatric Neuroradiology, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Mohamad Maghnie
- Department of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy.
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13
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Wei ST, Chen DC, Cho DY, Lin HL. Langerhans cell histiocytosis in monozygotic twins with central diabetes insipidus and hypophyseal masses. Asian J Neurosurg 2015; 10:105-7. [PMID: 25972939 PMCID: PMC4421945 DOI: 10.4103/1793-5482.145177] [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: 11/11/2022] Open
Abstract
Langerhans cell histiocytosis (LCH) is a systemic disease mainly affecting children and young adults. It can manifest as single system disorder or multi-system involvement. When the central nervous system is involved, the hypothalamic–pituitary axis is the most common location affected. Herein we report a rare case of Langerhans cell histiocytosis in monozygotic twins both with central diabetes and hypophyseal masses. This is the first report about LCH in monozygotic twins with hypophyseal lesions.
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Affiliation(s)
- Sung-Tai Wei
- Department of Neurosurgery, China Medical University and Hospital, Taichung, Taiwan, R.O.C
| | - Der-Cherng Chen
- Department of Neurosurgery, China Medical University and Hospital, Taichung, Taiwan, R.O.C
| | - Der-Yang Cho
- Department of Neurosurgery, China Medical University and Hospital, Taichung, Taiwan, R.O.C ; Graduate Institute of Immunology, China Medical University, Taichung, Taiwan, R.O.C
| | - Hung-Lin Lin
- Department of Neurosurgery, China Medical University and Hospital, Taichung, Taiwan, R.O.C
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Babiker AMI, Al Jurayyan NAM, Al Jurayyan RNA, Al Gadi I, Drop SLS. The clinical pattern of diabetes Insipidus in a large university hospital in the Middle East. J Trop Pediatr 2015; 61:100-5. [PMID: 25587001 DOI: 10.1093/tropej/fmu075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Diabetes insipidus is a rare but serious endocrine disorder. Paediatric patients were evaluated for polyuria at King Khalid University Hospital, Riyadh, Saudi Arabia, over a decade (2000-13). Relevant clinical examination and/or a triad of high serum osmolality, hypernatremia and low urine osmolality due to increased urine output confirmed the diagnosis. Water deprivation test was required in some cases with non-classic presentations. Appropriate brain imaging was performed whenever central diabetes insipidus (CDI) was suspected. Twenty-eight patients, 15 males (53.6%) and 13 females (46.4%), aged 0-17 years (mean: 6 years) were included. The calculated period prevalence was 7 in 10,000. In our cohort, 60.7% (17 of 28 patients) had CDI, 21.4% (6 of 28) were diagnosed with nephrogenic diabetes insipidus (NDI) and 17.9% (5 of 30) had psychogenic polydipsia. CDI was due to variable aetiology. Though CDI was the commonest, NDI was not a rare encounter in our community, possibly because of high consanguineous marriages.
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Affiliation(s)
- Amir M I Babiker
- Division of Paediatric Endocrinology, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Nasir A M Al Jurayyan
- Division of Paediatric Endocrinology, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Rushaid N A Al Jurayyan
- Department of Radiology and Medical imaging, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Iman Al Gadi
- Division of Paediatric Endocrinology, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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Di Iorgi N, Allegri AEM, Napoli F, Calcagno A, Calandra E, Fratangeli N, Vannati M, Rossi A, Bagnasco F, Haupt R, Maghnie M. Central diabetes insipidus in children and young adults: etiological diagnosis and long-term outcome of idiopathic cases. J Clin Endocrinol Metab 2014; 99:1264-72. [PMID: 24276447 DOI: 10.1210/jc.2013-3724] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Central diabetes insipidus (CDI) is considered idiopathic in 20% to 50% of affected subjects. OBJECTIVE The purpose of this study was to determine whether a systematic diagnostic workup could achieve better etiologic diagnosis in children and adolescents presenting with polyuria and polydipsia. DESIGN AND SETTING This is a prospective study conducted at a tertiary referral center. Patients underwent clinical and endocrine evaluations every 6 months and neuroimaging every 6 months for 2 years and yearly for 3 years. Endocrine function and neuroimaging were also reassessed after adult height achievement. PARTICIPANTS A total of 85 consecutive patients with CDI were enrolled at a median age of 7.5 years; those with idiopathic CDI were stratified based on pituitary stalk thickness. MAIN OUTCOME MEASURES To establish the etiology of CDI, we determined the time lag between its onset and the specific diagnosis, the long-term impact on pituitary function, and the overall long-term outcomes. RESULTS Of the subjects, 24 (28.2%) received an etiologic diagnosis at presentation and 11 (13%) within 2.5 years (n = 7 germinomas and n = 4 Langerhans cell histiocytosis), 7 (8.2%) were lost to follow-up, and 43 (50.6%) were considered to have idiopathic disease and were followed until the median age of 17.3 years. Neuroimaging identified 40 of 43 patients with self-limited inflammatory/autoimmune pituitary stalk thickness within the first 6 months, the severity of which was significantly correlated to pituitary dysfunction. The probability of >10-year-survival without an anterior pituitary defect was related to the severity of pituitary stalk thickness, and 53% showed permanent anterior pituitary defects. Three patients developed Langerhans cell histiocytosis and 1 developed Hodgkin lymphoma after a median of 9 and 13 years, respectively. CONCLUSIONS A diagnostic etiology was achieved in 96% of patients with CDI. Risk stratification based on the degree of pituitary stalk thickness is of prognostic value for long-term outcomes including permanent pituitary dysfunction. New guidance is provided for the management of these patients.
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Affiliation(s)
- Natascia Di Iorgi
- Department of Pediatrics (N.D.I., A.C., E.C., N.F., M.V., M.M.), Istituto Giannina Gaslini, University of Genova, 16147 Genova, Italy; and Department of Pediatrics (A.E.M.A., F.N.), Pediatric Neuroradiology (A.R.), and Epidemiology, Biostatistics and Committee's Unit (F.B., R.H.), Istituto Giannina Gaslini, 16147 Genova, Italy
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16
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Mohamed S, Osman A, Al Jurayyan NA, Al Nemri A, Salih MAM. Congenital toxoplasmosis presenting as central diabetes insipidus in an infant: a case report. BMC Res Notes 2014; 7:184. [PMID: 24674575 PMCID: PMC3986852 DOI: 10.1186/1756-0500-7-184] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 03/21/2014] [Indexed: 11/10/2022] Open
Abstract
Background Congenital toxoplasmosis has a wide range of presentation at birth varying from severe neurological features such as hydrocephalus and chorioretinitis to a well appearing baby, who may develop complications late in infancy. While neuroendocrine abnormalities associated with congenital toxoplasmosis are uncommon, isolated central diabetes insipidus is extremely rare. Case presentation Here, we report on a female infant who presented with fever, convulsions, and polyuria. Examination revealed weight and length below the 3rd centile along with signs of severe dehydration. Fundal examination showed bilateral chorioretinitis. This infant developed hypernatremia together with increased serum osmolality and decreased both urine osmolality and specific gravity consistent with central diabetes insipidus. Serology for toxoplasma specific immunoglobulin M was high for both the mother and the baby and polymerase chain reaction for toxoplasma deoxyribonucleic acid was positive in the infant confirming congenital toxoplasmosis. Brain computerized tomography scans demonstrated ventriculomegaly associated with cerebral and cortical calcifications. Fluid and electrolyte abnormalities responded to nasal vasopressin therapy. Conclusion This report highlights central diabetes inspidus as a rare presentation of congenital toxoplasmosis.
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Affiliation(s)
- Sarar Mohamed
- Department of Pediatrics (39), College of Medicine, King Saud University, P,O, Box 2925, 11461 Riyadh, Saudi Arabia.
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17
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Amat Madramany A, Gastaldo Simeón E, Revert Ventura A, Escobar Hoyos LA, Riesgo Suárez P. [Importance of long-term follow-up of diabetes insipidus; from lymphocytic hypophysitis to germinoma]. An Pediatr (Barc) 2014; 82:e108-12. [PMID: 24630998 DOI: 10.1016/j.anpedi.2013.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 12/17/2013] [Accepted: 12/26/2013] [Indexed: 11/26/2022] Open
Abstract
A case is presented of a 10-year old boy who had a hypothalamic-pituitary axis disorder. He initially presented with diabetes insipidus that progressed to panhypopituitarism. A hidden hypothalamic lesion should be suspected in all these cases, and should be followed up. New lesions were found in the pituitary stem three years later. Although tumor markers were negative, there was an increase in size, and a biopsy was performed. The histopathology reported a Lymphocytic Hypophysitis. There were increases in the tumor markers during the follow-up, thus a second biopsy was performed, with the diagnosis of Germinoma. Lymphocytic Hypophysitis is an uncommon diagnosis in children. Few cases have been reported, and in some cases, they were later diagnosed with Germinoma. We believe this case highlights the importance of the follow-up of children with Central Diabetes Insipidus with a normal MRI, as well as not taking the diagnosis of Lymphocytic Hypophysitis/lymphocytic Infundibular neurohypophysitis as definitive, as it is a rare diagnosis at this age, and could mask a Germinoma, as recorded in some cases.
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Affiliation(s)
- A Amat Madramany
- Servicio de Pediatría, Hospital Universitario de la Ribera, Alzira, Valencia, España.
| | - E Gastaldo Simeón
- Servicio de Pediatría, Hospital Universitario de la Ribera, Alzira, Valencia, España
| | - A Revert Ventura
- Servicio de Radiología, Hospital Universitario de la Ribera, Alzira, Valencia, España
| | - L A Escobar Hoyos
- Servicio de Radiología, Hospital Universitario de la Ribera, Alzira, Valencia, España
| | - P Riesgo Suárez
- Servicio de Neurocirugía, Hospital Universitario de la Ribera, Alzira, Valencia, España
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18
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Abstract
Kabuki syndrome is characterized by distinctive facial features, multiple anomalies and mental retardation. In this syndrome, structural CNS abnormalities are commonly observed, but congenital abnormalities in the pituitary gland or hypothalamus have rarely been reported. We searched the published medical literature on the complications in hypothalamic pituitary axis in this syndrome. As a result, only nine patients with Kabuki syndrome had been reported to have complications in hypothalamic pituitary axis in previous papers. Among the nine reported patients and one presented case in this report, GH deficiency was the most frequent complication and found in six patients. Precocious puberty and central diabetes insipidus (DI) was identified in two cases, respectively, and ACTH deficiency was found in one. One case had combination of GH deficiency and central DI. Three of the 10 patients demonstrated abnormal pituitary findings in MRI study. Two of the six patients with GH deficiency were accompanied with premature thelarche. This review highlights that patients with Kabuki syndrome could present various clinical manifestations due to abnormalities in hypothalamic pituitary axis.
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Affiliation(s)
- Naoko Ito
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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Modawi I, Barger GR, Rossi NF. Central diabetes insipidus and adipsia due to astrocytoma: diagnosis and management. CEN Case Rep 2013; 2:11-16. [PMID: 28509212 DOI: 10.1007/s13730-012-0030-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 07/05/2012] [Indexed: 11/29/2022] Open
Abstract
Adipsia and/or diabetes insipidus is rarely a direct complication of astrocytoma. We report a young man with recurrence of anaplastic astrocytoma who presented as severe hypernatremia. This case highlights key diagnostic and therapeutic challenges: (1) the interpretation of the response to exogenous vasopressin in a patient with steroid-induced hyperglycemia and (2) the potential risk of brain edema and herniation if excess water is prescribed along with vasopressin supplementation. The patient was successfully managed with prescribed fluid replacement, daily weights, and regular electrolyte monitoring but no exogenous vasopressin for 8 months until he succumbed to his tumor.
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Affiliation(s)
- Imad Modawi
- Department of Internal Medicine, Wayne State University School of Medicine, 4160 John R. Street #908, Detroit, MI, 48201, USA.,John D. Dingell VA Medical Center, Detroit, MI, USA
| | - Geoffrey R Barger
- Department of Neurology, Wayne State University School of Medicine, Detroit, MI, USA.,Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - Noreen F Rossi
- Department of Internal Medicine, Wayne State University School of Medicine, 4160 John R. Street #908, Detroit, MI, 48201, USA. .,Department of Physiology, Wayne State University School of Medicine, Detroit, MI, USA. .,John D. Dingell VA Medical Center, Detroit, MI, USA.
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20
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Yang YH, Lin JJ, Hsia SH, Wu CT, Wang HS, Hung PC, Chou ML, Hsieh MY, Lin KL. Central diabetes insipidus in children with acute brain insult. Pediatr Neurol 2011; 45:377-80. [PMID: 22114999 DOI: 10.1016/j.pediatrneurol.2011.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 09/02/2011] [Indexed: 10/15/2022]
Abstract
Central diabetes insipidus occurs in patients with overwhelming central nervous system injuries, and may be associated with brain death. The clinical picture of children with acquired central diabetes insipidus after acute brain insult is seldom reported. We retrospectively reviewed cases dating from January 2000-February 2008 at a tertiary pediatric intensive care unit. Fifty-four patients (28 girls, 26 boys), aged 3 months to 18 years, were enrolled. Etiologies included severe central nervous system infection (35.2%), hypoxic-ischemic events (31.5%), head injury (18.5%), and vascular lesions (14.8%). In 39 (72.2%) patients, diabetes insipidus was diagnosed during the first 2 days after acute central nervous system injury, and 40 (74.0%) developed maximum serum sodium concentrations of >160 mEq/L. In 16, sequential cerebral salt wasting syndrome developed after their initial diabetes insipidus presentation. Overall mortality at 2 months after admission was 77.8%. Our results demonstrate that patients who develop central diabetes insipidus after acute central nervous system injury manifest high mortality. Development of central diabetes insipidus within the first 2 days and a maximum plasma sodium >160 mEq/L were significant predictors of outcomes.
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Affiliation(s)
- Yun-Hsuan Yang
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
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21
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Passeri E, Tufano A, Perrotta S, Ambrosi B, Corbetta S. Variable clinical presentations in a family with neurohypophysial diabetes insipidus. J Endocrinol Invest 2011; 34:889-90. [PMID: 22322538 DOI: 10.1007/bf03346735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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22
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Abstract
Fluid homeostasis requires adequate water intake, regulated by an intact thirst mechanism and appropriate free water excretion by the kidneys, mediated by appropriate secretion of arginine vasopressin (AVP, also known as antidiuretic hormone). AVP exerts its antidiuretic action by binding to the X chromosome-encoded V2 vasopressin receptor (V2R), a G protein coupled receptor on the basolateral membrane of renal collecting duct epithelial cells. After V2R activation, increased intracellular cyclic adenosine monophosphate mediates shuttling of the water channel aquaporin 2 to the apical membrane of collecting duct cells, resulting in increased water permeability and antidiuresis. Clinical disorders of water balance are common, and abnormalities in many steps involving AVP secretion and responsiveness have been described. This article focuses on the principal disorders of water balance, diabetes insipidus, and the syndrome of inappropriate antidiuretic hormone secretion.
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Affiliation(s)
- Sayali A. Ranadive
- Department of Endocrinology, Children's Hospital and Research Center Oakland, 747 52nd Street, Oakland, CA 94609, USA
| | - Stephen M. Rosenthal
- Department of Pediatrics, Division of Endocrinology, University of California San Francisco, 513 Parnassus Avenue, Room S672, San Francisco, CA 94143, USA,Corresponding author. (S.M. Rosenthal)
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23
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Paldino MJ, Faerber EN, Poussaint TY. Imaging tumors of the pediatric central nervous system. Radiol Clin North Am 2011; 49:589-616, v. [PMID: 21807164 DOI: 10.1016/j.rcl.2011.05.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Primary tumors of the central nervous system (CNS) are the second most common neoplasms in children and the leading cause of death in this patient population. The primary objective of this article is to describe the most common pediatric brain tumors and to offer an overview of their respective imaging features, primarily on magnetic resonance imaging. Precise anatomic characterization is essential for developing an appropriate differential diagnosis. Once equipped with this critical information, physicians should be better able to make firm diagnoses, leading to improved disease management and patient outcomes in the setting of CNS tumors of childhood.
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Affiliation(s)
- Michael J Paldino
- Division of Neuroradiology, Department of Radiology, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA.
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24
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Secco A, Allegri AEM, di Iorgi N, Napoli F, Calcagno A, Bertelli E, Olivieri I, Pala G, Parodi S, Gastaldi R, Rossi A, Maghnie M. Posterior pituitary (PP) evaluation in patients with anterior pituitary defect associated with ectopic PP and septo-optic dysplasia. Eur J Endocrinol 2011; 165:411-20. [PMID: 21750044 DOI: 10.1530/eje-11-0437] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Andrea Secco
- Department of Pediatrics Epidemiology and Biostatistics Section, Scientific Directorate Pediatric Neuroradiology, IRCCS G. Gaslini Institute, University of Genova, Largo Gerolamo Gaslini 5, 16147 Genova, Italy
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Marchand I, Barkaoui MA, Garel C, Polak M, Donadieu J. Central diabetes insipidus as the inaugural manifestation of Langerhans cell histiocytosis: natural history and medical evaluation of 26 children and adolescents. J Clin Endocrinol Metab 2011; 96:E1352-60. [PMID: 21752883 DOI: 10.1210/jc.2011-0513] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
CONTEXT Isolated central diabetes insipidus (CDI) can be the first manifestation of Langerhans cell histiocytosis (LCH), creating diagnostic dilemmas such as dysgerminoma and other inflammatory lesions. METHOD In 2010, the French national LCH registry had enrolled 1236 LCH patients under 18 yr of age. Isolated CDI was the initial presentation of LCH in 26 patients. We reviewed their clinical and magnetic resonance imaging (MRI) features. RESULTS Median age at the diagnosis of CDI was 9.6 yr (1.8-16.3), and median follow-up after CDI diagnosis was 9.9 yr (3.5-26.6). In addition to CDI, two patients had visual field defects, four had secondary amenorrhea, and 11 had anterior pituitary deficiency. Cerebral imaging (including computed tomography in two cases), performed in 22 patients within 3 months of CDI diagnosis, showed pituitary stalk thickening in 14 patients, which was moderate (3.0-7 mm) in nine cases and marked (>7 mm) in five cases. In eight cases, the lesion extended to the floor of the third ventricle. One child with LCH presented with a mild enlarged sellar content. During follow-up, 22 patients developed extrapituitary involvement, mainly of bone (n = 15), lung (n = 9), and skin (n = 9). Pituitary biopsy was performed in eight cases and was conclusive in six cases. CONCLUSIONS Pituitary stalk thickening can be observed in LCH as well as lesions extending to the floor of the third ventricle. In all cases but one, the intrasellar content was not enlarged. Long-term follow-up with close attention to bone, skin, and lung disorders may lead to the diagnosis of LCH.
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Affiliation(s)
- Isis Marchand
- Service d'Endocrinologie Pédiatrique, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
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Comparison of the efficacy of four viral vectors for transducing hypothalamic magnocellular neurosecretory neurons in the rat supraoptic nucleus. J Neurosci Methods 2011; 197:238-48. [PMID: 21392530 DOI: 10.1016/j.jneumeth.2011.02.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 02/09/2011] [Accepted: 02/24/2011] [Indexed: 02/08/2023]
Abstract
Since transgenes were first cloned into recombinant adenoviruses almost 30 years ago, a variety of viral vectors have become important tools in genetic research. Viruses adeptly transport genetic material into eukaryotic cells, and replacing all or part of the viral genome with genes of interest or silencing sequences creates a method of gene expression modulation in which the timing and location of manipulations can be specific. The hypothalamo-neurohypophyseal system (HNS), consisting of the paraventricular (PVN) and supraoptic (SON) nuclei in the hypothalamus, regulates fluid balance homeostasis and is highly plastic, yet tightly regulated by extracellular fluid (ECF) osmolality and volume. Its reversible plasticity and physiological relevance make it a good system for studying interactions between gene expression and physiology. Here, four viral vectors were compared for their ability to transduce magnocellular neurosecretory neurons (MNCs) of the SON in adult rats. The vectors included an adenovirus, a lentivirus (HIV) and two serotypes of adeno-associated viruses (AAV5 and AAV2). Though adenovirus and AAV2 vectors have previously been used to transduce SON neurons, HIV and AAV5 have not. All four vectors transduced MNCs, but the AAV vectors were the most effective, transducing large numbers of MNCs, with minimal or no glial transduction. The AAV vectors were injected using a convection enhanced delivery protocol to maximize dispersal through the tissue, resulting in the transduction of neurons throughout the anterior to posterior length of the SON (∼1.5mm). AAV5, but not AAV2, showed some selectivity for SON neurons relative to those in the surrounding hypothalamus.
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27
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Hayward RM, Nicolin G, Kennedy C, Joy H, Davies JH. From idiopathic diabetes insipidus to neurodegenerative Langerhans cell histiocytosis--an unusual presentation and progression of disease. J Pediatr Endocrinol Metab 2011; 24:811-4. [PMID: 22145482 DOI: 10.1515/jpem.2011.298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Diabetes insipidus (DI) is rare in childhood and has a wide-ranging aetiology including the involvement of uncontrolled proliferation of dendritic cells in the hypothalamic-pituitary axis, characteristic of Langerhans cell histiocytosis (LCH). DI may manifest as a sequela of multisystem LCH disease involving skin, bone, liver, spleen and lymph nodes. In very rare cases patients diagnosed with LCH exhibit neurodegenerative changes, such as severe ataxia, tremor, dysarthria and intellectual impairment. We report a 2 1/2-year-old boy who presented initially with apparent idiopathic DI, developed anterior pituitary hormone deficiency and progressive neurological deterioration secondary to neurodegenerative LCH.
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Affiliation(s)
- Rachel M Hayward
- Paediatric Endocrinology, Southampton University Hospitals NHS Trust, Southampton, UK
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28
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Carman KB, Yarar C, Yakut A, Adapinar B. Septo-optic dysplasia plus: a patient with diabetes insipidus. Pediatr Neurol 2010; 43:76-8. [PMID: 20682211 DOI: 10.1016/j.pediatrneurol.2010.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Accepted: 03/01/2010] [Indexed: 10/19/2022]
Abstract
The association of septo-optic dysplasia and cortical dysplasia is described as septo-optic dysplasia-plus. Reports on patients with septo-optic dysplasia-plus have been rare. We describe a 4-year-old girl with septo-optic dysplasia-plus syndrome, characterized by septo-optic dysplasia with schizencephaly, pachygyria, and diabetes insipidus.
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Affiliation(s)
- Kursat Bora Carman
- Department of Pediatrics, Eskisehir Osmangazi University, Eskisehir, Turkey.
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30
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Abstract
Fluid homeostasis requires adequate water intake, regulated by an intact thirst mechanism and appropriate free water excretion by the kidneys, mediated by appropriate secretion of arginine vasopressin (AVP, also known as antidiuretic hormone). AVP exerts its antidiuretic action by binding to the X chromosome-encoded V2 vasopressin receptor (V2R), a G protein-coupled receptor on the basolateral membrane of renal collecting duct epithelial cells. After V2R activation, increased intracellular cyclic adenosine monophosphate mediates shuttling of the water channel aquaporin 2 to the apical membrane of collecting duct cells, resulting in increased water permeability and antidiuresis. Clinical disorders of water balance are common, and abnormalities in many steps involving AVP secretion and responsiveness have been described. This article focuses on the principal disorders of water balance, diabetes insipidus, and the syndrome of inappropriate antidiuretic hormone secretion.
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Affiliation(s)
- Sayali A. Ranadive
- Department of Endocrinology, Children's Hospital and Research Center Oakland, 747 52
| | - Stephen M. Rosenthal
- Department of Pediatrics, Division of Endocrinology, University of California San Francisco, San Francisco, California
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31
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Endocrine late effects: manifestations and treatments. Cancer Treat Res 2009. [PMID: 19834668 DOI: 10.1007/b109924_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Ranadive SA, Ersoy B, Favre H, Cheung CC, Rosenthal SM, Miller WL, Vaisse C. Identification, characterization and rescue of a novel vasopressin-2 receptor mutation causing nephrogenic diabetes insipidus. Clin Endocrinol (Oxf) 2009; 71:388-93. [PMID: 19170711 PMCID: PMC5881569 DOI: 10.1111/j.1365-2265.2008.03513.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE X-linked nephrogenic diabetes insipidus (XNDI), caused by mutations in the V2 vasopressin receptor (V2R), is clinically distinguished from central diabetes insipidus (CDI) by elevated serum vasopressin (AVP) levels and unresponsiveness to 1-desamino-8-d-arginine vasopressin (DDAVP). We report two infants with XNDI, and present the characterization and functional rescue of a novel V2R mutation. PATIENTS Two male infants presented with poor growth and hypernatraemia. Both patients had measurable pretreatment serum AVP and polyuria that did not respond to DDAVP, suggesting NDI. However, both also had absent posterior pituitary bright spot on MRI, which is a finding more typical of CDI. METHODS The AVPR2 gene encoding V2R was sequenced. The identified novel missense mutation was re-created by site-directed mutagenesis and expressed in HEK293 cells. V2R activity was assessed by the ability of transfected cells to produce cAMP in response to stimulation with DDAVP. Membrane localization of V2R was assessed by fluorescence microscopy. RESULTS Patient 1 had a deletion of AVPR2; patient 2 had the novel mutation L57R. In transiently transfected HEK293 cells, DDAVP induced detectable but severely impaired L57R V2R activity compared to cells expressing wild-type V2R. Fluorescence microscopy showed that myc-tagged wild-type V2R localized to the cell membrane while L57R V2R remained intracellular. A nonpeptide V2R chaperone, SR121463, partially rescued L57R V2R function by allowing it to reach the cell membrane. CONCLUSIONS L57R V2R has impaired in vitro activity that can be partially improved by treatment with a V2R chaperone. The posterior pituitary hyperintensity may be absent in infants with XNDI.
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Affiliation(s)
- Sayali A Ranadive
- Department of Pediatrics, Division of Endocrinology, University of California San Francisco, San Francisco, CA 94143, USA
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Kundra M, Stankovic C, Gupta N, Thomas R, Hamre M, Mahajan P. Epidemiologic findings of cancer detected in a pediatric emergency department. Clin Pediatr (Phila) 2009; 48:404-9. [PMID: 18832531 DOI: 10.1177/0009922808323110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study describes epidemiologic findings of pediatric cancer diagnosed in the emergency department (ED) setting. Medical records are retrospectively reviewed on all patients in the hospital's cancer database between 2000 and 2004 who were diagnosed as having cancer or whose oncologic diagnosis was missed during their ED presentation. Of 427 patients identified in the cancer database, 18% (77 of 427) are analyzed. Oncologic diagnosis was missed in 5% (4 of 77) of the eligible patients initially presenting to the ED. The incidence of cancer in the ED is 22.8 cases per 100,000 ED visits. The most prevalent cancer is related to the hematologic system (37.7%), followed by the central nervous system (31.2%) and the abdomen (22.1%). Hematologic, central nervous system, and abdominal cancers constitute approximately 90% of all childhood cancers. Cancer is diagnosed frequently in our ED patient population. Based on the prevalence of certain tumors, the diagnostic approach to children with hematologic, neurologic, or abdominal complaints should include evaluation for any underlying cancer.
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Affiliation(s)
- Manu Kundra
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI 48201, USA.
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Lin JJ, Lin KL, Hsia SH, Wu CT, Wang HS. Combined central diabetes insipidus and cerebral salt wasting syndrome in children. Pediatr Neurol 2009; 40:84-7. [PMID: 19135619 DOI: 10.1016/j.pediatrneurol.2008.09.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Revised: 09/08/2008] [Accepted: 09/10/2008] [Indexed: 10/21/2022]
Abstract
Central diabetes insipidus, a common consequence of acute central nervous system injury, causes hypernatremia; cerebral salt wasting syndrome can cause hyponatremia. The two conditions occurring simultaneous are rarely described in pediatric patients. Pediatric cases of combined diabetes insipidus and cerebral salt wasting after acute central nervous system injury between January 2000 and December 2007 were retrospectively reviewed, and clinical characteristics were systemically assessed. Sixteen patients, aged 3 months to 18 years, met study criteria: 11 girls and 5 boys. The most common etiologies were severe central nervous system infection (n = 7, 44%) and hypoxic-ischemic event (n = 4, 25%). In 15 patients, diabetes insipidus was diagnosed during the first 3 days after acute central nervous system injury. Onset of cerebral salt wasting syndrome occurred 2-8 days after the onset of diabetes insipidus. In terms of outcome, 13 patients died (81%) and 3 survived under vegetative status (19%). Central diabetes insipidus and cerebral salt wasting syndrome may occur after acute central nervous system injury. A combination of both may impede accurate diagnosis. Proper differential diagnoses are critical, because the treatment strategy for each entity is different.
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Affiliation(s)
- Jainn-Jim Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
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Hayanga AJ, Kohen R, Egeland B, Charles A, Spoor M, Kuzon WM, Napolitano LM. Central Diabetes Insipidus: A Rare Perioperative Cause of Severe Hypernatraemia. Anaesth Intensive Care 2008; 36:235-41. [DOI: 10.1177/0310057x0803600215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In this case report we describe the management of severe hypernatraemia following inadvertent water restriction. A 21-year-old woman with no reported medical history presented on transfer from an outside hospital with a complex volar upper extremity injury. Management both operatively and postoperatively involved a prolonged period of fasting which limited her access to drinking water. Collateral history revealed that she had previously drunk copious amounts of water during the course of any given day and this had served to alleviate the dramatic symptoms of hypernatraemia that were rapidly manifest when her normal intake was curtailed. We outline the fluid management, administration of desmopressin and her subsequent recovery. A literature review of the management of central diabetes insipidus is also covered.
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Affiliation(s)
- A. J. Hayanga
- Divisions of Acute Care Surgery and Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, United States of America
| | - R. Kohen
- Divisions of Acute Care Surgery and Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, United States of America
| | - B. Egeland
- Divisions of Acute Care Surgery and Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, United States of America
| | - A. Charles
- Divisions of Acute Care Surgery and Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, United States of America
| | - M. Spoor
- Divisions of Acute Care Surgery and Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, United States of America
| | - W. M. Kuzon
- Divisions of Acute Care Surgery and Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, United States of America
| | - L. M. Napolitano
- Divisions of Acute Care Surgery and Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan, United States of America
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Bibliography. Current world literature. Hematology and oncology. Curr Opin Pediatr 2008; 20:107-13. [PMID: 18197049 DOI: 10.1097/mop.0b013e3282f572b6] [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: 01/19/2023]
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Rivkees SA, Dunbar N, Wilson TA. The management of central diabetes insipidus in infancy: desmopressin, low renal solute load formula, thiazide diuretics. J Pediatr Endocrinol Metab 2007; 20:459-69. [PMID: 17550208 DOI: 10.1515/jpem.2007.20.4.459] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Infants consume most of their calories as formula. Because of this large fluid intake, infants normally produce dilute urine, not far off from that seen in individuals with diabetes insipidus (DI). Infants with DI are therefore prone to water intoxication if fixed antidiuresis is achieved using the long-acting vasopressin analog desmopressin (DDAVP), which induces a state of high urine concentration. DI treatment approaches applied to older children and adults, who consume the their calories as solids, are difficult to apply to infants with DI. When used in infants, oral and intranasal DDAVP can be associated with wide swings in serum sodium concentration (SNA). In comparison, precisely administered subcutaneous doses of DDAVP can be successfully used in infants with DI, and appear to be superior to oral or intranasal DDAVP therapy. Alternatively, consistent eunatremia can be simply achieved in infantile DI using low renal solute load (RSL) formula and thiazide diuretics. Low RSL formula reduces obligatory urinary water losses, and thiazide diuretics concentrate the urine to levels seen in normal formula-fed infants. This report addresses treatment options of DI in infancy and the delicate management issues involved.
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Affiliation(s)
- Scott A Rivkees
- Department ofPediatrics, Yale Child Health Research Center, Section of Pediatric Endocrinology, Yale University, New Haven, CT, USA.
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Chung SJ, Lee SY, Shin CH, Yang SW. Clinical, endocrinological and radiological courses in patients who was initially diagnosed as idiopathic central diabetes insipidus. KOREAN JOURNAL OF PEDIATRICS 2007. [DOI: 10.3345/kjp.2007.50.11.1110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Seung Joon Chung
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Seong Yong Lee
- Department of Pediatrics, Seoul Metropolitan Boramae Hospital, Seoul, Korea
| | - Choong Ho Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Sei Won Yang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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