Diabetes insipidus as a hallmark neuroendocrine complication of neonatal meningitis

Waterhouse-Friderichsen Syndrome and Central Diabetes Insipidus Due to Escherichia coli Meningitis

Waterhouse-Friderichsen syndrome and central diabetes insipidus are uncommon but potentially fatal endocrine and metabolic diseases. Waterhouse-Friderichsen syndrome is defined as adrenal insufficiency caused by adrenal hemorrhage, which is typically bilateral and most frequently due to meningococcal infection. It is usually diagnosed by necropsy. Central diabetes insipidus in children is often caused by trauma, intracranial lesions, autoimmune diseases, and infections. In addition, it can be caused by mutations in the AVP-NPII gene, although this occurs typically later in childhood rather than in the neonatal period. This report describes a term infant who developed Escherichia coli meningitis, which resulted in septic shock and disseminated intravascular coagulation. Abdominal ultrasound led to an early diagnosis of bilateral adrenal hemorrhage and appropriate treatment with corticosteroids. Symptomatic central diabetes insipidus developed a few days after the onset of meningitis. Intravenous vasopressin was effective in resolving hemodynamic instability. In conclusion, sepsis and meningitis may have severely affected the endocrine system in this patient. Early diagnosis and appropriate treatment for both diseases may have resulted in better clinical outcomes for this patient.

Neuroimaging of central diabetes insipidus

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.

A Cross-Sectional Study of Hyponatremia Associated with Acute Central Nervous System Infections

Hyponatremia can occur with central nervous system (CNS) infections, but the frequency and severity may depend on the organism and nature of CNS involvement. In this cross-sectional study at a large Australian hospital network from 2015 to 2018, we aimed to determine the prevalence and severity of hyponatremia associated with CNS infection clinical syndromes, and the association with specific organisms. We examined the results of cerebrospinal fluid analysis from lumbar punctures performed in 184 adult patients with a serum sodium below 135 mmol/L who had abnormal cerebrospinal fluid analysis and a clinical syndrome consistent with an acute CNS infection (meningitis or encephalitis). Hyponatremia affected 39% of patients and was more severe and frequent in patients with encephalitis compared to meningitis (odds ratio = 3.03, 95% CI: 1.43–6.39, after adjusting for age). Hyponatremia was present on admission in 85% of cases. Herpes simplex virus infection was associated with the highest odds of hyponatremia (odds ratio = 3.25, 95% CI: 1.13–7.87) while enterovirus infection was associated with the lowest (odds ratio = 0.36, 95% CI: 0.14–0.92), compared to cases without an isolated organism. We concluded that the risk of hyponatremia may vary by the organism isolated but the clinical syndrome was a useful surrogate for predicting the probability of developing hyponatremia.

Central Diabetes Insipidus in an Infant with Pneumococcal Meningitis

BACKGROUND

Central diabetes is an infrequent complication reported in the neonatal period.

CASE REPORT

CDI as a complication of Streptococcus pneumoniae (S. pneumoniae) sepsis and meningitis in a 9-day-old boy is presented. The CDI developed on day 3 after admission and was controlled with nasal vasopressin on the 20th day of admission. Despite antibiotic support, the child died from Acinetobacter sepsis at 4 months of age, but the CDI was well controlled.

CONCLUSION

Newborns with bacterial meningitis can develop CDI as a sequalae. Treatment of the CDI with nasal vasopressin can be successful in this period. To our knowledge, this is the first newborn of CDI associated with S. pneumoniae meningitis.

Enteroviral Meningoencephalitis Complicated by Central Diabetes Insipidus in a Neonate: A Case Report and Review of the Literature

Enterovirus is a known cause of central nervous system infection in the neonatal population and typically has a benign course; however, neurologic complications have been reported. We describe what we believe to be the first documented case of enteroviral meningoencephalitis complicated by central diabetes insipidus in a neonate.

Prenatal presentation of transient central diabetes insipidus

INTRODUCTION

Nephrogenic diabetes insipidus (DI) in the foetus has been described as a rare presentation of severe polyhydramnios.

DISCUSSION

We report a case of foetal central DI, characterised by severe polyhydramnios. Significant polyuria was noted at birth. Serum AVP level was un-measurable (<0.5 pg/ml). A dramatic response to intravenous dDAVP (desmopressin) was noted confirming central DI. Further investigations did not reveal a recognised cause for central or nephrogenic DI. The infant thrived well on a small dose of oral desmopressin until the age of 12 months. At 13 months, a water deprivation test revealed a normal ability to concentrate urine without desmopressin, and subsequently, the infant has thrived without further treatment. The transient nature of the central DI remains obscure but could be explained by a maturational delay in the tissues involved in AVP synthesis or release, during intrauterine life and infancy.

CONCLUSION

Both nephrogenic and central DI should be considered as a cause of severe polyhydramnios. This may help to guide prompt intensive management and investigation, with attention to vascular access, central venous pressure, urine output monitoring and replacement.

The management of central diabetes insipidus in infancy: desmopressin, low renal solute load formula, thiazide diuretics

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.

Predictors of diabetes insipidus after transsphenoidal surgery: a review of 881 patients

OBJECT

Diabetes insipidus (DI) is a common complication of transsphenoidal surgery. The purpose of this study was to elucidate patient- and surgery-specific risk factors for DI.

METHODS

The perioperative records of 881 patients who had undergone transsphenoidal microsurgery at the authors' institution between January 1995 and June 2001 were reviewed. Among 857 patients without preoperative DI, the overall incidence of immediate postoperative DI was 18.3%, with 12.4% of patients requiring treatment with desmopressin at some point during their hospitalization. Persistent DI requiring long-term treatment with desmopressin was noted in 2% of all patients. An observable intraoperative cerebrospinal fluid (CSF) leak was strongly associated with an increased incidence of both transient (33.3%) and persistent (4.4%) DI. Craniopharyngioma and Rathke cleft cyst (RCC) were also associated with an increased incidence of transient and persistent DI, whereas repeated operation was not. Among patients with pituitary adenomas, those with Cushing's disease had an increased risk of transient (22.2%), but not persistent, DI. Patients with a microadenoma were more likely to suffer transient DI than those harboring a macroadenoma (21.6 compared with 14.3%) but were not more likely to experience persistent DI.

CONCLUSIONS

Diabetes insipidus remains a common complication of transsphenoidal surgery; however, it is most frequently transient in nature. Patients with an intraoperative CSF leak, a microadenoma, a craniopharyngioma, or an RCC appear to have an increased risk of transient DI. Risk factors for persistent DI include an intraoperative CSF leak, a craniopharyngioma, or an RCC.