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Galbiati F, Stamatiades GA, Bi WL, Abreu AP. Hypothalamic and Pituitary Dysfunction After Extensive Brain Surgery: There Is Thirst for More Knowledge. JCEM CASE REPORTS 2023; 1:luad137. [PMID: 38021079 PMCID: PMC10652246 DOI: 10.1210/jcemcr/luad137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Indexed: 12/01/2023]
Abstract
Craniopharyngiomas are tumors originating from the infundibular stalk, extending to the parasellar and suprasellar region, thereby conferring multiple risks of this region. In particular, hypothalamic and pituitary damage related to its natural history as well as treatment effects of craniopharyngiomas substantially affect life expectancy and quality of life. Here, we describe an adult patient presenting with polyuria, memory, and visual field impairment secondary to concurrent craniopharyngioma and intraventricular glioma. He was treated with surgical resection with postoperative course notable for hypothalamic-pituitary dysfunction, including central hypothyroidism, central adrenal insufficiency, arginine vasopressin deficiency (AVP-D, formerly diabetes insipidus) with loss of sense of thirst, and hypothalamic hypothermia. The adipsia, combined with memory dysfunction, challenged the management of constant fluctuations in his sodium (129-168 mEq/L), with ultimate treatment through vasopressin repletion, fixed fluid intake, strict urine output monitoring, and close counseling of the patient and his caregiver. This case exemplifies the complexity of the endocrine care of patients with craniopharyngiomas and highlights the need for step-wise algorithms in the treatment of hypothalamic deficiencies such as adipsia.
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Affiliation(s)
- Francesca Galbiati
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - George A Stamatiades
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Wenya L Bi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Ana Paula Abreu
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Tomkins M, Lawless S, Martin-Grace J, Sherlock M, Thompson CJ. Diagnosis and Management of Central Diabetes Insipidus in Adults. J Clin Endocrinol Metab 2022; 107:2701-2715. [PMID: 35771962 PMCID: PMC9516129 DOI: 10.1210/clinem/dgac381] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Indexed: 11/19/2022]
Abstract
Central diabetes insipidus (CDI) is a clinical syndrome which results from loss or impaired function of vasopressinergic neurons in the hypothalamus/posterior pituitary, resulting in impaired synthesis and/or secretion of arginine vasopressin (AVP). AVP deficiency leads to the inability to concentrate urine and excessive renal water losses, resulting in a clinical syndrome of hypotonic polyuria with compensatory thirst. CDI is caused by diverse etiologies, although it typically develops due to neoplastic, traumatic, or autoimmune destruction of AVP-synthesizing/secreting neurons. This review focuses on the diagnosis and management of CDI, providing insights into the physiological disturbances underpinning the syndrome. Recent developments in diagnostic techniques, particularly the development of the copeptin assay, have improved accuracy and acceptability of the diagnostic approach to the hypotonic polyuria syndrome. We discuss the management of CDI with particular emphasis on management of fluid intake and pharmacological replacement of AVP. Specific clinical syndromes such as adipsic diabetes insipidus and diabetes insipidus in pregnancy as well as management of the perioperative patient with diabetes insipidus are also discussed.
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Affiliation(s)
- Maria Tomkins
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sarah Lawless
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Julie Martin-Grace
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mark Sherlock
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Chris J Thompson
- Correspondence: Chris Thompson, Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland.
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Thompson CJ, Costello RW, Crowley RK. Management of hypothalamic disease in patients with craniopharyngioma. Clin Endocrinol (Oxf) 2019; 90:506-516. [PMID: 30614015 DOI: 10.1111/cen.13929] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/02/2019] [Accepted: 01/03/2019] [Indexed: 12/21/2022]
Abstract
Patients with craniopharyngioma experience excess morbidity and mortality when compared with the background population and with other hypopituitary patients. Large, suprasellar tumours which form micropapillae into surrounding structures can cause hypothalamic damage before any therapeutic intervention; attempted gross total resection can lead to hypothalamic obesity, sleep disorders, thirst disorders and dysregulation of temperature as well as panhypopituitarism. The management of tumour bulk and the pathophysiology of hypothalamic complications have been reviewed extensively. We present a practical, clinical approach to management of hypothalamic disease in a patient with craniopharyngioma and highlight potential targets for future pharmacological or surgical intervention.
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Affiliation(s)
- Christopher J Thompson
- Academic Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Richard W Costello
- Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
- Department of Respiratory Medicine, Beaumont Hospital, Dublin, Ireland
| | - Rachel K Crowley
- Department of Endocrinology, St Vincent's University Hospital, Dublin, Ireland
- University College, Dublin, Ireland
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Pérez MA, Millán HA, Naranjo JA, Flórez Romero A. Adipsic diabetes insipidus secondary to craniopharyngioma resection. BMJ Case Rep 2019; 12:12/1/e225903. [PMID: 30709829 DOI: 10.1136/bcr-2018-225903] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Adipsic diabetes insipidus is an infrequent disease which may be associated with craniopharyngioma. It may be secondary to the tumour's extension, as well as to resection of the mass. We present the case of a 24-year-old woman with a history of delayed puberty and hypothyroidism, but no prior study reports. She consulted due to a headache with warning signs associated with altered visual acuity. Brain MRI was performed which showed signs of a non-adenomatous lesion with suprasellar and hypothalamic extension. Following transcranial surgery, she developed diabetes insipidus criteria, with absence of thirst documented during the hospitalisation. The histopathological findings confirmed the diagnosis of craniopharyngioma. The patient was treated with desmopressin and received recommendations regarding rehydration according to the quantification of losses, with electrolyte stabilisation.
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Affiliation(s)
- María Alejandra Pérez
- Internal Medicine, Fundación Cardioinfantil, Bogotá, Colombia.,Internal medicine, Fundación Cardioinfantil, Bogotá, Colombia
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Dalan R, Chin H, Hoe J, Chen A, Tan H, Boehm BO, Chua KS. Adipsic Diabetes Insipidus-The Challenging Combination of Polyuria and Adipsia: A Case Report and Review of Literature. Front Endocrinol (Lausanne) 2019; 10:630. [PMID: 31620086 PMCID: PMC6759785 DOI: 10.3389/fendo.2019.00630] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 08/30/2019] [Indexed: 12/18/2022] Open
Abstract
Adipsic Diabetes Insipidus is a rare hypothalamic disorder characterized by a loss of thirst in response to hypernatraemia accompanied by diabetes insipidus. These occur secondary to a congregation of defects in the homeostatic mechanisms of water balance. A 27-year old Chinese female presented with Adipsic Diabetes Insipidus after cerebral arteriovenous malformation (AVM) surgery. Initial diagnosis and management was extremely challenging. Long term management required a careful interplay between low dose vasopressin analog treatment and fluids. Detailed charts of medication and sodium balance are described in the case presentation. We performed a literature search of similarly reported cases and describe the possible pathogenesis, etiology, clinical presentation, acute and chronic management, and prognosis.
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Affiliation(s)
- Rinkoo Dalan
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
- Metabolic Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore
- Department of Medicine, Yong Loo School of Medicine, National University of Singapore, Singapore, Singapore
- *Correspondence: Rinkoo Dalan
| | - Hanxin Chin
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jeremy Hoe
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Abel Chen
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Huiling Tan
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Bernhard Otto Boehm
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
- Metabolic Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore
| | - Karen SuiGeok Chua
- Department of Rehabilitation Medicine, Tan Tock Seng Hospital, Singapore, Singapore
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Garrahy A, Moran C, Thompson CJ. Diagnosis and management of central diabetes insipidus in adults. Clin Endocrinol (Oxf) 2019; 90:23-30. [PMID: 30269342 DOI: 10.1111/cen.13866] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 09/25/2018] [Accepted: 09/26/2018] [Indexed: 02/05/2023]
Abstract
Central diabetes insipidus (CDI) is characterized by hypotonic polyuria due to impairment of AVP secretion from the posterior pituitary. In clinical practice, it needs to be distinguished from renal resistance to the antidiuretic effects of AVP (nephrogenic DI), and abnormalities of thirst appreciation (primary polydipsia). As nephrogenic diabetes insipidus is rare in adults, unless they are treated with lithium salts, the practical challenge is how to differentiate between CDI and clinical disorders of excess thirst. The differential diagnosis is usually straight forward, but the recommended gold standard test, the water deprivation test, is not without interpretative pitfalls. The addition of the measurement of plasma AVP concentrations improves diagnostic accuracy, but the radioimmunoassay for AVP is technically difficult, and is only available in a few specialized centres. More recently, the measurement of plasma copeptin concentrations has been claimed to provide a reliable alternative to measurement of plasma AVP, without the sampling handling challenges. In addition, the measurement of thirst ratings can help the differentiation between CDI and primary polydipsia. Once the diagnosis of CDI is biochemically certain, investigations to determine the cause of AVP deficiency are needed. In this review, we will outline the diagnostic approach to polyuria, revisit the caveats of the water deprivation test and review recent data on value of adding AVP/copeptin measurement. We will also discuss treatment strategies for CDI, with analysis of potential complications of treatment.
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Affiliation(s)
- Aoife Garrahy
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
| | - Carla Moran
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
| | - Christopher J Thompson
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
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Zhang Y, Wang D, Feng Y, Zhang W, Zeng X. Juvenile-onset gout and adipsic diabetes insipidus: A case report and literature review. J Int Med Res 2018; 46:4829-4836. [PMID: 30270804 PMCID: PMC6259371 DOI: 10.1177/0300060518800114] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The prevalence of juvenile-onset gout has been increasing. Hereditary factors and secondary diseases should be considered in these patients. Adipsic diabetes insipidus (ADI) is characterized by arginine vasopressin (AVP) deficiency, which results in hypotonic polyuria, and dysfunction of thirst osmoreceptors, which results in failure to generate a thirst sensation in response to hypernatremia. We herein report a case of a boy with gouty arthritis, refractory hyperuricemia, prominent hypernatremia, a high creatinine concentration, and a history of surgery for a hypothalamic hamartoma. The patient was diagnosed with central diabetes insipidus after endocrine evaluation. Because he never had symptoms of thirst, the final diagnosis was corrected to ADI. This is the first report of gout due to chronic ADI in an adolescent. Volume contraction due to ADI might be one cause of hyperuricemia and renal impairment in such patients. Moreover, AVP deficiency might directly lead to low urate clearance due to the lack of vasopressin receptor 1 stimulation. Lack of polydipsia and polyuria may delay the diagnosis of ADI and lead to severe complications of a chronic hyperosmolar status. Sufficient and effective establishment of normovolemia is critical for these patients.
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Affiliation(s)
- Yun Zhang
- 1 Department of General Internal Medicine, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Dongmei Wang
- 2 Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yiding Feng
- 3 Department of Internal Medicine, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Wen Zhang
- 4 Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Xuejun Zeng
- 1 Department of General Internal Medicine, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
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Abstract
INTRODUCTION Adipsic diabetes insipidus (ADI) is a very rare disorder, characterized by hypotonic polyuria due to arginine vasopressin (AVP) deficiency and failure to generate the sensation of thirst in response to hypernatraemia. As the sensation of thirst is the key homeostatic mechanism that prevents hypernatraemic dehydration in patients with untreated diabetes insipidus (DI), adipsia leads to failure to respond to aquaresis with appropriate fluid intake. This predisposes to the development of significant hypernatraemia, which is the typical biochemical manifestation of adipsic DI. METHODS A literature search was performed to review the background, etiology, management and associated complications of this rare condition. RESULTS ADI has been reported to occur in association with clipping of an anterior communicating artery aneurysm following subarachnoid haemorrhage, major hypothalamic surgery, traumatic brain injury and toluene exposure among other conditions. Management is very difficult and patients are prone to marked changes in plasma sodium concentration, in particular to the development of severe hypernatraemia. Associated hypothalamic disorders, such as severe obesity, sleep apnoea and thermoregulatory disorders are often observed in patients with ADI. CONCLUSION The management of ADI is challenging and is associated with significant morbidity and mortality. Prognosis is variable; hypothalamic complications lead to early death in some patients, but recent reports highlight the possibility of recovery of thirst.
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Affiliation(s)
- Martín Cuesta
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Beaumont Road, Dublin 9, Co., Dublin, Ireland
| | - Mark J Hannon
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Beaumont Road, Dublin 9, Co., Dublin, Ireland
| | - Christopher J Thompson
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Beaumont Road, Dublin 9, Co., Dublin, Ireland.
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Garrahy A, Sherlock M, Thompson CJ. MANAGEMENT OF ENDOCRINE DISEASE: Neuroendocrine surveillance and management of neurosurgical patients. Eur J Endocrinol 2017; 176:R217-R233. [PMID: 28193628 DOI: 10.1530/eje-16-0962] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 01/30/2017] [Accepted: 02/13/2017] [Indexed: 01/01/2023]
Abstract
Advances in the management of traumatic brain injury, subarachnoid haemorrhage and intracranial tumours have led to improved survival rates and an increased focus on quality of life of survivors. Endocrine sequelae of the acute brain insult and subsequent neurosurgery, peri-operative fluid administration and/or cranial irradiation are now well described. Unrecognised acute hypopituitarism, particularly ACTH/cortisol deficiency and diabetes insipidus, can be life threatening. Although hypopituitarism may be transient, up to 30% of survivors of TBI have chronic hypopituitarism, which can diminish quality of life and hamper rehabilitation. Patients who survive SAH may also develop hypopituitarism, though it is less common than after TBI. The growth hormone axis is most frequently affected. There is also accumulating evidence that survivors of intracranial malignancy, who have required cranial irradiation, may develop hypopituitarism. The time course of the development of hormone deficits is varied, and predictors of pituitary dysfunction are unreliable. Furthermore, diagnosis of GH and ACTH deficiency require dynamic testing that can be resource intensive. Thus the surveillance and management of neuroendocrine dysfunction in neurosurgical patients poses significant logistic challenges to endocrine services. However, diagnosis and management of pituitary dysfunction can be rewarding. Appropriate hormone replacement can improve quality of life, prevent complications such as muscle atrophy, infection and osteoporosis and improve engagement with physiotherapy and rehabilitation.
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Affiliation(s)
- Aoife Garrahy
- Academic Department of EndocrinologyBeaumont Hospital/RCSI Medical School, Dublin, Ireland
| | | | - Christopher J Thompson
- Academic Department of EndocrinologyBeaumont Hospital/RCSI Medical School, Dublin, Ireland
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