Corticotropin deficiency: a rare cause of hyponatremia mimicking SIADH

Isolated adrenocorticotropin deficiency in a child with Kabuki syndrome

A 6 year-old Chinese boy with Kabuki syndrome presented with hypoglycemic seizure. He was diagnosed to have isolated adrenocorticotropin deficiency. To our knowledge, this is the first case of Kabuki syndrome with isolated adrenocorticotropin deficiency in the literature.

Symptomatic hyponatremia as a presenting sign of hypothalamic-pituitary disease: a syndrome of inappropriate secretion of antidiuretic hormone (SIADH)-like glucocorticosteroid responsive condition

Hyponatremia associated with high urine osmolality is usually caused by inappropriate secretion of antidiuretic hormone. However, secondary hypoadrenalism is also accompanied by hyponatremia and with features indistinguishable from the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). As secondary hypoadrenalism requires a specific treatment, a high index of suspicion and appropriate hormonal testing are required to differentiate between these two entities. We retrospectively studied 10 patients with a previously undiagnosed hypothalamic-pituitary disease who presented with an acute symptomatic hyponatremia. Mean age (+/-SD) was 65.1+/-8.4 yr. Mean serum sodium was 120.7+/-2.9 nmol/l and urinary osmolality, 453.9+/-74 mosmol/kg. Serum creatinine, urea and uric acid were low. Mean serum morning cortisol was low, 104.0+/-55.2 nmol/l. High-dose ACTH test showed adequate increment of serum cortisol in 3 out of 7 patients tested. Two of these 3 patients did not respond adequately to the low-dose ACTH test. Endocrine evaluation disclosed partial or complete hypopituitarism in all 10 patients. Six patients had pituitary macroadenomas, one had a craniopharyngioma, one patient had a large aneurysm of the internal carotid with sellar destruction and two others had empty sella. Treatment by fluid restriction did not affect serum sodium levels significantly. In contrast, all patients achieved normal sodium when treated by glucocorticosteroid. Central hypoadrenalism should be considered in any patient presenting with hyponatremia with high urine osmolality. Low-dose ACTH test should be performed and followed by appropriate endocrine and imaging studies. Hyponatremia in these patients is promptly corrected by glucocorticosteroid replacement.

Interactions between neurohypophysial hormones and the ACTH-adrenocortical axis

Figure 5 summarizes the aspects of the interaction of the HPA and magnocellular systems discussed above. Hormones classically considered confined to the magnocellular-neurohypophysial system are found in the parvocellular-long portal system and are known to be paramount in the hypophysiotropic control of ACTH release. It is now clear that hormones from the posterior pituitary can influence the secretion of ACTH via the short portal circulation and, possibly, by recirculation. There is some evidence that circulating AVP may affect adrenal sensitivity to ACTH. Corticosteroids, in addition to inhibiting parvocellular CRH and ACTH release, may inhibit the release of AVP from the neurohypophysis. The converse is also true in that patients with adrenal insufficiency may have an SIAD-like scenario. CRH may be synthesized in, and secreted from, magnocellular OT neurons and may be involved in the control of neurohypophysial function.