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Tuli G, Munarin J, De Sanctis L. The diagnostic role of arginine-stimulated copeptin in the differential diagnosis of polyuria-polydipsia syndrome (PPS) in pediatric age. Endocrine 2024; 84:677-682. [PMID: 38155322 DOI: 10.1007/s12020-023-03671-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/15/2023] [Indexed: 12/30/2023]
Abstract
PURPOSE In recent years, copeptin stimulation through arginine administration has been evaluated as a new potential tool in the differential diagnosis of polyuria-polydipsia syndrome (PPS) in adults; to date very few data, all retrospective, exist in pediatric age. The aim of this prospective study is to evaluate the diagnostic performance of the arginine-stimulation test for copeptin in a cohort of pediatric patients affected by PPS. METHODS All children (<18 years) referred to the Department of Pediatric Endocrinology of the Regina Margherita Children Hospital for polyuria-polydipsia in the period January 2021-June 2023 were enrolled. The Arginine-stimulation test for copeptin was performed in all patients presenting PPS after water deprivation test (WDT). Patients with polyuria-polydipsia were then classified as having primary polyuria (PP), complete and partial central diabetes insipidus (CDI), according to the standardized interpretation. Arginine-stimulation test for copeptin was also performed in a control cohort. RESULTS A significant difference in arginine-stimulated copeptin values was observed at baseline (p = 0.005), at 60 min (p = 0.01), and at 90 min (p = 0.005) in 7 subjects presenting PP, 6 patients affected by CDI and 50 subjects of the control cohort. Plasma osmolality values remained stable at all measurements. The arginine-stimulated copeptin test demonstrated sensitivity and specificity of 100%, whereas the sensitivity of the WDT test was 83.3% and the specificity was 85.7%. CONCLUSION Given the reliability and the minor adverse effects and costs, the copeptin level after arginine administration could replace the WDT in the diagnostic workup of these in pediatric age.
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Affiliation(s)
- Gerdi Tuli
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy.
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, Turin, Italy.
| | - Jessica Munarin
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, Turin, Italy
| | - Luisa De Sanctis
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, Turin, Italy
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Kadel A, Kharal N, Sapkota S, Pokhrel P, Sharma AK, Bhattarai A, Raut M, Dubey RK, Tuladhar ET, Sharma VK, Niraula A. Antidiuretic hormone deficiency secondary to inactive hydrocephalus: a case report. J Med Case Rep 2024; 18:133. [PMID: 38555457 PMCID: PMC10981802 DOI: 10.1186/s13256-024-04467-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 02/20/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Diabetes insipidus is a syndrome characterized by polyuria, which is almost always associated with polydipsia. The most frequent cause is central diabetes insipidus, which is the result of an inadequate secretion of the antidiuretic hormone, and diagnosis involves differentiating it from other causes of polyuria and polydipsia. CASE PRESENTATION Here, we present a clinical case of a previously healthy 13-year-old Nepali boy, who, in December 2022, was found to have intense polydipsia accompanied by polyuria. He had bilateral lower limb weakness at the time of presentation. Biochemical evaluation demonstrated raised serum sodium (181 mEq/L), serum creatinine (78 μmol/L), and serum uric acid (560 μmol/L) with suppressed serum potassium (2.7 mEq/L), which was the major concern to the clinicians. Further laboratory workup revealed an increased serum osmolarity (393.6 mOsm/kg) with reduced urine osmolarity (222.7 mOsm/kg). On contrast magnetic resonance imaging of the brain, a thick-walled third ventricular cyst with bilateral foramen obstruction, thin membrane-like structure at top of aqueduct of Sylvius with gross obstructive hydrocephalus (inactive), and compressed and thinned pituitary gland with no bright spot was observed. The laboratory findings, radiological findings, and case presentation provided the provisional diagnosis of diabetes insipidus due to hydrocephalus and third ventricular cyst. CONCLUSIONS Central diabetes insipidus due to hydrocephalus, though rare, can have serious complications including the predilection to develop a deficit of other pituitary hormones. Thus, even if hydrocephalus is dormant with normal intracranial pressure, it must be addressed during investigations of central diabetes insipidus.
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Affiliation(s)
- Anuradha Kadel
- Department of Clinical Biochemistry, Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Nepal
| | - Nikita Kharal
- Department of Clinical Biochemistry, Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Nepal
| | - Srijana Sapkota
- Department of Clinical Biochemistry, Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Nepal
| | - Prakash Pokhrel
- Department of Clinical Biochemistry, Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Nepal
| | - Arun Kumar Sharma
- Department of Paediatrics, Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Nepal
| | - Aseem Bhattarai
- Department of Clinical Biochemistry, Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Nepal
| | - Mithileshwer Raut
- Department of Clinical Biochemistry, Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Nepal
| | - Raju Kumar Dubey
- Department of Clinical Biochemistry, Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Nepal
| | - Eans Tara Tuladhar
- Department of Clinical Biochemistry, Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Nepal
| | - Vijay Kumar Sharma
- Department of Clinical Biochemistry, Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Nepal
| | - Apeksha Niraula
- Department of Clinical Biochemistry, Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Nepal.
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Giglio A, Reccius A, Ferre A, Dreyse J. Severe osmotic demyelination syndrome with cortical involvement in the context of severe hyponatremia and central diabetes insipidus: an uncommon presentation of an unusual combination. BMJ Case Rep 2024; 17:e257210. [PMID: 38171637 PMCID: PMC10773298 DOI: 10.1136/bcr-2023-257210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Osmotic demyelination syndrome (ODS) with cerebral cortical involvement is a rare complication of severe hyponatremia correction. Careful management of hyponatremia is crucial, particularly in patients with risk factors, such as alcohol use disorder and diabetes insipidus. CASE A patient in his 40s with a history of alcohol use disorder and central diabetes insipidus developed ODS after a 24 mEq/L osmolar increase during the treatment of hyponatremia. The patient's condition progressed into locked-in syndrome and then improved to spastic tetraparesis after cortical basal ganglia ODS improved. DISCUSSION The differential diagnosis of cortical demyelination includes laminar cortical necrosis, being the interpretation of Apparent Diffusion Coefficient (ADC) MRI sequence is a useful tool.This case underscores the need to investigate and improve diagnosis and treatment strategies in patients with ODS. It also emphasises the significance of careful hyponatremia correction and frequent monitoring, particularly in patients with known risk factors for ODS.
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Affiliation(s)
- Andres Giglio
- Critical Care Department, Finis Terrae University, Santiago, Chile
- Critical Care Department, Clinica Las Condes Hospital, Santiago, Chile
| | - Andres Reccius
- Critical Care Department, Finis Terrae University, Santiago, Chile
- Critical Care Department, Clinica Las Condes Hospital, Santiago, Chile
- Neurology Department, Clinica Las Condes Hospital, Santiago, Chile
| | - Andres Ferre
- Critical Care Department, Finis Terrae University, Santiago, Chile
- Critical Care Department, Clinica Las Condes Hospital, Santiago, Chile
| | - Jorge Dreyse
- Critical Care Department, Finis Terrae University, Santiago, Chile
- Critical Care Department, Clinica Las Condes Hospital, Santiago, Chile
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Alexander A, Zacharin M. Endocrine features of Langerhans cell histiocytosis in paediatric patients: A 30-year review. J Paediatr Child Health 2024; 60:24-27. [PMID: 38031464 DOI: 10.1111/jpc.16521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 09/20/2023] [Accepted: 11/07/2023] [Indexed: 12/01/2023]
Abstract
Langerhans cell histiocytosis (LCH) is a rare proliferative disorder characterised as an inflammatory myeloid neoplasia. Endocrine manifestations of LCH, particularly central diabetes insipidus (CDI), have been described from the 1940s, through case studies and small cohort analyses. There are limited Australian paediatric data described in recent literature. AIM To document the incidence of endocrine features in paediatric patients with LCH, treated at a tertiary paediatric centre in Victoria, Australia. METHODS Retrospective chart review of electronic medical records and oncology database of patients with LCH managed at a tertiary paediatric centre. Patients were excluded if a biopsy did not suggest LCH or if records were incomplete. RESULTS One hundred seventy-one patients were identified and 141 records of patients diagnosed with LCH over the last 30 years were assessed for endocrinopathies, from diagnosis to last documented follow-up. Mean age at diagnosis was 5 years 8 months. Of these, 15% (n = 21) had CDI, 7% had growth hormone deficiency (GHD) (n = 10) and 8% (n = 11) had more than one endocrinopathy noted during follow-up. Forty percent (n = 57) were pre-pubertal at the time of audit or upon discharge from tertiary services. CONCLUSIONS Ongoing pituitary assessment, in addition to CDI, is required to detect evolving deficiencies of GHD and gonadotropins as these can be subtle, late or missed. Close follow-up of growth and progression through puberty, even if discharged from tertiary care, is essential.
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Affiliation(s)
- Ashley Alexander
- Department of Endocrinology and Diabetes, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Margaret Zacharin
- Department of Endocrinology and Diabetes, Royal Children's Hospital, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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5
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Boot C. The laboratory investigation of diabetes insipidus: A review. Ann Clin Biochem 2024; 61:19-31. [PMID: 36650746 DOI: 10.1177/00045632231154391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Diabetes insipidus (DI) is a group of disorders that lead to inappropriate production of large volumes of dilute urine. The three main forms are central DI (CDI), nephrogenic DI (NDI) and primary polydipsia (PP). Differentiating CDI/NDI from PP is important as patients with true DI are at risk of severe dehydration without treatment. Biochemical testing is key in the diagnosis of DI. The indirect water deprivation test (WDT) is commonly used in the investigation of DI but has drawbacks including being cumbersome and sometimes producing equivocal results. Direct measurement of AVP has theoretical advantages but has generally only been used in specialist centres. Disadvantages include the requirement to measure AVP under hypertonic stimulation and pre-analytical/analytical challenges. Copeptin (CT-proAVP) is a proxy marker for AVP that is more stable, easier to measure and has been studied more widely in recent years. Historically, the evidence supporting the diagnostic performance of these tests has been relatively poor, being based on a few small, usually single-centre studies. However more recent, well-designed prospective studies are improving the evidence base for investigation of DI. These studies have focused on the utility of copeptin measurements during stimulation tests. There is evidence that measurement of copeptin under stimulation offers improved diagnostic performance compared to the WDT. There is currently a lack of systematic, evidence-based guidelines on the diagnosis of DI, but as the quality of the evidence defining the diagnostic performance of tests for DI continues to improve, a clearer consensus on the optimal approach should become achievable.
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Affiliation(s)
- Christopher Boot
- Blood Sciences, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Fujisawa H, Takeuchi T, Ishii A, Muto J, Kamasaki H, Suzuki A, Sugimura Y. Absence of anti-rabphilin-3A antibodies in children and young adults with idiopathic central diabetes insipidus: a potential clue to elucidating a tumor etiology. Hormones (Athens) 2023; 22:747-758. [PMID: 37697216 PMCID: PMC10651553 DOI: 10.1007/s42000-023-00484-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 08/31/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Central diabetes insipidus (CDI) is a rare condition caused by various underlying diseases, including neoplasms, autoimmune diseases, and infiltrative diseases. Differentiating between CDI etiologies is difficult. What has initially been classified as "idiopathic" central diabetes insipidus might in fact underlie various pathogenic mechanisms that are less understood to date and/or are not obvious at initial presentation. Therefore, even if idiopathic CDI is diagnosed at the time of onset, it is common for tumors such as germinoma to develop during surveillance. Crucially, a delayed diagnosis of germinoma may be associated with a worse prognosis. Recently, the presence of anti-rabphilin-3A antibodies has been found to be a highly sensitive and specific marker of lymphocytic infundibuloneurohypophysitis, an autoimmune-mediated CDI. CASE PRESENTATION We herein present two cases, namely, a 13-year-old boy (patient 1) and a 19-year-old young man (patient 2) who were diagnosed with idiopathic CDI. In both patients, panhypopituitarism developed. Magnetic resonance imaging revealed pituitary stalk thickening and pituitary swelling approximately 1 1/2 years after the onset of CDI. Western blotting did not reveal the presence of anti-rabphilin-3A antibodies in serum in either patient, suggesting that autoimmune mechanisms might not be involved. Both patients were subsequently diagnosed with germinoma on pathological examination. They received chemotherapy, followed by radiation therapy. Notably, testosterone and insulin-like growth factor-1 levels normalized, and libido and beard growth recovered after chemoradiotherapy in patient 2. CONCLUSION Our data suggest that the absence of anti-rabphilin-3A antibodies in young patients clinically diagnosed with idiopathic CDI may increase the probability of the development of non-lymphocytic lesions, including germinoma. We thus recommend a more attentive approach at the onset of these diseases.
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Affiliation(s)
- Haruki Fujisawa
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Takako Takeuchi
- Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, 060-8556, Japan
| | - Akira Ishii
- Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, 060-8556, Japan
| | - Jun Muto
- Department of Neurosurgery, Fujita Health University, Toyoake, Aichi, 470-1192, Japan
| | - Hotaka Kamasaki
- Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, 060-8556, Japan
| | - Atsushi Suzuki
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Yoshihisa Sugimura
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan.
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Affiliation(s)
- John Newell-Price
- From the School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
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8
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Angelousi A, Alexandraki KI, Mytareli C, Grossman AB, Kaltsas G. New developments and concepts in the diagnosis and management of diabetes insipidus (AVP-deficiency and resistance). J Neuroendocrinol 2023; 35:e13233. [PMID: 36683321 DOI: 10.1111/jne.13233] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/10/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023]
Abstract
Diabetes insipidus (DI) is a disorder characterised by the excretion of large amounts of hypotonic urine, with a prevalence of 1 per 25,000 population. Central DI (CDI), better now referred to as arginine vasopressin (AVP)-deficiency, is the most common form of DI resulting from deficiency of the hormone AVP from the pituitary. The less common nephrogenic DI (NDI) or AVP-resistance develops secondary to AVP resistance in the kidneys. The majority of causes of DI are acquired, with CDI developing when more than 80% of AVP-secreting neurons are damaged. Inherited/familial CDI causes account for approximately 1% of cases. Although the pathogenesis of NDI is unclear, more than 280 disease-causing mutations affecting the AVP2 protein or AVP V2 receptor, as well as in aquaporin 2 (AQP2), have been described. Although the cAMP/protein kinase A pathway remains the major regulatory pathway of AVP/AQP2 action, in vitro data have also revealed additional cAMP independent pathways of NDI pathogenesis. Diagnosing partial forms of DI, and distinguishing them from primary polydipsia, can be challenging, previously necessitating the use of the water deprivation test. However, measurements of circulating copeptin levels, especially after stimulation, are increasingly replacing the classical tests in clinical practice because of their ease of use and high sensitivity and specificity. The treatment of CDI relies on desmopressin administration, whereas NDI requires the management of any underlying diseases, removal of offending drugs and, in some cases, administration of diuretics. A better understanding of the pathophysiology of DI has led to novel evolving therapeutic agents that are under clinical trial.
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Affiliation(s)
- Anna Angelousi
- First Department of Internal Medicine, Unit of Endocrinology, Laikon Hospital, Athens, Greece
| | | | - Chrysoula Mytareli
- First Department of Internal Medicine, Unit of Endocrinology, Laikon Hospital, Athens, Greece
| | - Ashley B Grossman
- Green Templeton College, University of Oxford, Oxford, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, UK
- NET Unit, Royal Free Hospital, London, UK
| | - Gregory Kaltsas
- First Department of Propaedeutic Internal Medicine, Laikon Hospital, National & Kapodistrian University of Athens, Athens, Greece
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Arima H, Cheetham T, Christ-Crain M, Cooper D, Drummond J, Gurnell M, Levy M, McCormack A, Newell-Price J, Verbalis JG, Wass J. Changing the Name of Diabetes Insipidus: A Position Statement of the Working Group for Renaming Diabetes Insipidus. J Clin Endocrinol Metab 2022; 108:1-3. [PMID: 36355385 PMCID: PMC9759163 DOI: 10.1210/clinem/dgac547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Indexed: 11/12/2022]
Abstract
Recent data show that patients with a diagnosis of diabetes insipidus (DI) are coming to harm. Here we give the rationale for a name change to arginine vasopressin deficiency and resistance for central and nephrogenic DI, respectively.
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Affiliation(s)
- Hiroshi Arima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Timothy Cheetham
- Department of Pediatric Endocrinology, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
- Great North Children's Hospital (GNCH), Newcastle upon Tyne NE1 4LP, UK
| | - Mirjam Christ-Crain
- Correspondence: Mirjam Christ-Crain, MD, PhD, Division of Endocrinology and Diabetes, University hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland. ; or Joseph G. Verbalis, MD, Division of Endocrinology and Metabolism, Georgetown University Medical Center, Washington, DC 20007, USA.
| | | | - Juliana Drummond
- Department of Internal Medicine, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG CEP 31270-901, Brazil
| | - Mark Gurnell
- Wellcome-MRC Institute of Metabolic Science, University of Cambridge & Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Miles Levy
- Department of Endocrinology, University Hospitals of Leicester NHS Trust, Leicester LE3 9QP, UK
| | - Ann McCormack
- Department of Endocrinology, St Vincent's Hospital, Sydney, NSW 2010, Australia
- Garvan Institute of Medical Research, Sydney, NSW 2010, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW 2052, Australia
| | - John Newell-Price
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield S10 2RX, UK
| | - Joseph G Verbalis
- Correspondence: Mirjam Christ-Crain, MD, PhD, Division of Endocrinology and Diabetes, University hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland. ; or Joseph G. Verbalis, MD, Division of Endocrinology and Metabolism, Georgetown University Medical Center, Washington, DC 20007, USA.
| | - John Wass
- Department of Endocrinology, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
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Iraqi HM, Pigarova E, Zacharieva S, Colao A, Baraf L, Tsoli M, Doknic M, Bitti SR, Giordano R, Barbot M, Akirov A, Witek P, Serebro M, Auer MK, Tóth M, Shimon I. Idiopathic central diabetes insipidus in a large cohort of patients: the hypopituitarism ENEA rare observational (HEROS) study. Pituitary 2022; 25:982-987. [PMID: 36260240 DOI: 10.1007/s11102-022-01277-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 11/26/2022]
Abstract
Central Diabetes Insipidus (CDI) is mainly associated with structural pathologies of the hypothalamic-pituitary area. Etiologies underlying CDI are identified in most patients, however idiopathic CDI is reported in 13-17% of cases after excluding other etiologies. The Hypopituitarism ENEA Rare Observational Study (HEROS study) retrospectively collected data of patients with idiopathic CDI from 14 pituitary centers in 9 countries. The cohort included 92 patients (59 females 64%), mean age at diagnosis was 35.4 ± 20.7 years, and a mean follow up of 19.1 ± 13.5 years following CDI diagnosis. In 6 women, diagnosis was related to pregnancy. Of 83 patients with available data on pituitary imaging, 40(48%) had normal sellar imaging, and 43(52%) had pathology of the posterior pituitary or the stalk, including loss of the bright spot, posterior pituitary atrophy or stalk enlargement. Anterior pituitary hormone deficiencies at presentation included hypogonadism in 6 (6.5%) patients (5 females), and hypocortisolism in one; during follow-up new anterior pituitary deficiencies developed in 6 patients. Replacement treatment with desmopressin was given to all patients except one, usually with an oral preparation. During follow up, no underlying disease causing CDI was identified in any patient. Patients with idiopathic CDI following investigation at baseline are stable with no specific etiology depicted during long-term follow-up.
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Affiliation(s)
- H Masri Iraqi
- Endocrine Institute, Rabin Medical Center - Beilinson Hospital, 39 Jabotinsky St, Petach Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - E Pigarova
- Endocrinology Research Centre, Moscow, Russia
| | | | - A Colao
- Federico II University of Naples, Naples, Italy
| | - L Baraf
- Soroka University Medical Center, Beer Sheva, Israel
| | - M Tsoli
- Laiko University Hospital, Athens, Greece
| | - M Doknic
- Neuroendocrine Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | | | - M Barbot
- University Hospital of Padova, Padua, Italy
| | - A Akirov
- Endocrine Institute, Rabin Medical Center - Beilinson Hospital, 39 Jabotinsky St, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - P Witek
- Medical University of Warsaw, Warsaw, Poland
| | - M Serebro
- Tel Aviv-Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M K Auer
- Medizinische Klinik and Poliklinik IV, Klinikum Der Universität München, LMU München, Munich, Germany
| | - M Tóth
- Semmelweis University, Budapest, Hungary
| | - I Shimon
- Endocrine Institute, Rabin Medical Center - Beilinson Hospital, 39 Jabotinsky St, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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11
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Nahum U, Refardt J, Chifu I, Fenske WK, Fassnacht M, Szinnai G, Christ-Crain M, Pfister M. Machine learning-based algorithm as an innovative approach for the differentiation between diabetes insipidus and primary polydipsia in clinical practice. Eur J Endocrinol 2022; 187:777-786. [PMID: 36201166 DOI: 10.1530/eje-22-0368] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 10/05/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Differentiation between central diabetes insipidus (cDI) and primary polydipsia (PP) remains challenging in clinical practice. Although the hypertonic saline infusion test led to high diagnostic accuracy, it is a laborious test requiring close monitoring of plasma sodium levels. As such, we leverage machine learning (ML) to facilitate differential diagnosis of cDI. DESIGN We analyzed data of 59 patients with cDI and 81 patients with PP from a prospective multicenter study evaluating the hypertonic saline test as new test approach to diagnose cDI. Our primary outcome was the diagnostic accuracy of the ML-based algorithm in differentiating cDI from PP patients. METHODS The data set used included 56 clinical, biochemical, and radiological covariates. We identified a set of five covariates which were crucial for differentiating cDI from PP patients utilizing standard ML methods. We developed ML-based algorithms on the data and validated them with an unseen test data set. RESULTS Urine osmolality, plasma sodium and glucose, known transsphenoidal surgery, or anterior pituitary deficiencies were selected as input parameters for the basic ML-based algorithm. Testing it on an unseen test data set resulted in a high area under the curve (AUC) score of 0.87. A further improvement of the ML-based algorithm was reached with the addition of MRI characteristics and the results of the hypertonic saline infusion test (AUC: 0.93 and 0.98, respectively). CONCLUSION The developed ML-based algorithm facilitated differentiation between cDI and PP patients with high accuracy even if only clinical information and laboratory data were available, thereby possibly avoiding cumbersome clinical tests in the future.
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Affiliation(s)
- Uri Nahum
- Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital Basel, University of Basel, Basel, Switzerland
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Julie Refardt
- Departments of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Irina Chifu
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Wuerzburg, Wuerzburg, Germany
| | - Wiebke K Fenske
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University Hospital of Bonn, Bonn, Germany
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Wuerzburg, Wuerzburg, Germany
- Central Laboratory, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Gabor Szinnai
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- Pediatric Endocrinology and Diabetology, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Mirjam Christ-Crain
- Departments of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Marc Pfister
- Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital Basel, University of Basel, Basel, Switzerland
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
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12
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Iwamoto Y, Mori S, Tatsumi F, Sugisaki T, Dan K, Katakura Y, Kimura T, Shimoda M, Nakanishi S, Mune T, Kaneto H. Central Diabetes Insipidus Due to IgG4-related Hypophysitis That Required over One Year to Reach the Final Diagnosis Due to Symptoms Being Masked by Sialadenitis. Intern Med 2022; 61:3541-3545. [PMID: 35569983 PMCID: PMC9790782 DOI: 10.2169/internalmedicine.9365-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Pituitary inflammation due to IgG4-related disease is a rare condition and is sometimes accompanied by central diabetes insipidus. Central diabetes insipidus produces a strong thirst sensation, which may be difficult to distinguish when complicated by salivary insufficiency. A 45-year-old man was admitted to our department for a thorough examination of his thirst and polyuria. He had suddenly developed these symptoms more than one year earlier and visited an oral surgeon. Swelling of the left submandibular gland, right parotid gland, and cervical lymph nodes had been observed. Since his IgG4 level was relatively high at 792 mg/dL and a lip biopsy showed high plasmacytoid infiltration around the gland ducts, he had been diagnosed with IgG4-related disease. He had started taking 0.4 mg/kg/day of prednisolone, and his chief complaint temporarily improved. However, since the symptom recurred, he was referred to our institution. After admission, to examine the cause of his thirst and polyuria, we performed a water restriction test, vasopressin loading test, hypertonic saline loading test and pituitary magnetic resonance imaging. Based on the findings, we diagnosed him with central diabetes insipidus due to IgG4-related hypophysitis. We increased the dose of prednisolone to 0.6 mg/kg/day and started 10 μg/day of intranasal desmopressin. His symptoms were subsequently alleviated, and his serum IgG4 level finally normalized. We should remember that IgG4-related disease can be accompanied by hypophysitis and that central diabetes insipidus is brought about by IgG4-related hypophysitis. This case report should remind physicians of the fact that pituitary inflammation due to IgG4-related disease is very rare and can be masked by symptoms due to salivary gland inflammation, which can lead to pitfalls in the diagnosis in clinical practice.
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Affiliation(s)
- Yuichiro Iwamoto
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Shigehito Mori
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Fuminori Tatsumi
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Toshitomo Sugisaki
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Kazunori Dan
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Yukino Katakura
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Tomohiko Kimura
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Masashi Shimoda
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Shuhei Nakanishi
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Tomoatsu Mune
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
| | - Hideaki Kaneto
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Japan
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13
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Molitch ME. Central diabetes insipidus from a patient's perspective. Lancet Diabetes Endocrinol 2022; 10:682-683. [PMID: 36007537 DOI: 10.1016/s2213-8587(22)00225-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/01/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Mark E Molitch
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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14
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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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15
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Abstract
BACKGROUND Novel coronavirus disease 2019 (COVID-19) mainly affects the lungs, but can involve several other organs. The diagnosis of acute and chronic sequelae is one of the challenges of COVID-19. The current literature proposes that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may involve the hypothalamic-pituitary axis. In this case report, we present a unique case of new-onset central diabetes insipidus secondary to the COVID-19 disease in a 54-year-old woman. CASE PRESENTATION A 54-year-old woman presented with the history of excessive thirst, polyuria, and polydipsia, six weeks after being infected by COVID-19. Laboratory tests revealed low urine osmolarity and increased serum osmolarity, and the patient was diagnosed with central diabetes insipidus. After administration of nasal desmopressin, urinary osmolarity increased, and the patient's symptoms improved. However, to stabilize her condition, desmopressin treatment was required. CONCLUSIONS We reported a unique case of diabetes insipidus in a COVID-19 patient. Central diabetes insipidus may be included in clinical manifestations of the COVID-19, in case of new-onset polyuria and polydipsia following COVID-19 disease. Nevertheless, a causal relationship has not been established between the symptoms of the patient and the SARS-CoV-2 infection.
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Affiliation(s)
- Ali Yavari
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Sharifan
- Virtual School of Medical Education and Management, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Mosadegh Khah
- Endocrinology Department, AJA University of Medical Science, Tehran, Iran.
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16
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Abstract
Central diabetes insipidus (CDI) is a complex disorder in which large volumes of dilute urine are excreted due to arginine-vasopressin deficiency, and it is caused by a variety of disorders affecting the hypothalamic-posterior pituitary network. The differential diagnosis is challenging and requires a detailed medical history, physical examination, biochemical approach, imaging studies, and, in some cases, histological confirmation. Magnetic resonance imaging is the gold standard method for evaluating congenital or acquired cerebral and pituitary stalk lesions. Pituitary stalk size at presentation could be normal, but it may change over time, depending on the underlying condition, while other brain areas or organs may become involved during follow-up. Early diagnosis and treatment are crucial to avoid central nervous system damage and germ cell tumor dissemination and to minimize complications of multiple pituitary hormone defects. We provide a practical update on the diagnosis and management of patients with CDI and highlight several pitfalls that may complicate the differential diagnosis of conditions presenting with polyuria and polydipsia. The need for a careful and close follow-up of patients with apparently idiopathic CDI is particularly emphasized because the underlying condition may be recognized over time. The clinical scenario that we outline at the beginning of this article represents the basis for the discussion about how the etiological diagnosis of CDI can be overlooked and demonstrates how a water intake and urine output improvement can be a sign of progressive damage of both hypothalamus and anterior pituitary gland with associated pituitary hormonal deficiencies.
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Affiliation(s)
- Giuseppa Patti
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Flavia Napoli
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Daniela Fava
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Emilio Casalini
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Natascia Di Iorgi
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Mohamad Maghnie
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
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Takahashi Y, Kameda H, Miya A, Nomoto H, Cho KY, Nakamura A, Nishimura H, Kimura H, Suzuki M, Konno S, Shimizu A, Matsuno Y, Okamoto M, Motegi H, Iwata N, Fujisawa H, Suzuki A, Sugimura Y, Miyoshi H, Atsumi T. Lymphocytic panhypophysitis and anti-rabphilin-3A antibody with pulmonary sarcoidosis. Pituitary 2022; 25:321-327. [PMID: 35088194 DOI: 10.1007/s11102-021-01200-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To explore the clinical significance of anti-rabphillin-3A antibody for the differential diagnosis of lymphocytic panhypophysitis. METHODS AND RESULTS A 58-year-old Japanese man developed uveitis of unknown cause in 2017. In 2019, he became aware of polyuria. In August 2020, he noticed transient diplopia and was diagnosed with right abducens nerve palsy. At the same time, he complained of fatigue and loss of appetite. Head magnetic resonance imaging demonstrated enlargement of the pituitary stalk and pituitary gland, corresponding to hypophysitis. Hormone stimulation tests showed blunted responses with respect to all anterior pituitary hormones. Central diabetes insipidus was diagnosed on the basis of a hypertonic saline loading test. Taking these findings together, a diagnosis of panhypopituitarism was made. Computed tomography showed enlargement of hilar lymph nodes. Biopsies of the hilar lymph nodes revealed non-caseating epithelioid cell granulomas that were consistent with sarcoidosis. Biopsy of the anterior pituitary revealed mild lymphocyte infiltration in the absence of IgG4-positive cells, non-caseating granulomas, or neoplasia. Western blotting revealed the presence of anti-rabphilin-3A antibody, supporting a diagnosis of lymphocytic panhypophysitis. Because the patient had no visual impairment or severe uveitis, we continued physiological hormone replacement therapy and topical steroid therapy for the uveitis. CONCLUSION To the best of our knowledge, this is the first case of anti-rabphilin 3A antibody positive lymphocytic panhypophysitis comorbid with sarcoidosis, diagnosed by both pituitary and hilar lymph node biopsy. The utility of anti-rabphilin-3A antibody for the differential diagnosis of hypophysitis like this case should be clarified with further case studies.
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Affiliation(s)
- Yuka Takahashi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Hiraku Kameda
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan.
| | - Aika Miya
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Hiroshi Nomoto
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Kyu Yong Cho
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Akinobu Nakamura
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Hiroki Nishimura
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hirokazu Kimura
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaru Suzuki
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Satoshi Konno
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Ai Shimizu
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Japan
| | - Yoshihiro Matsuno
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Japan
| | - Michinari Okamoto
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroaki Motegi
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Naoko Iwata
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
- Department of Endocrinology and Diabetes, Daido Hospital, Nagoya, Japan
| | - Haruki Fujisawa
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
| | - Atsushi Suzuki
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
| | - Yoshihisa Sugimura
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
| | - Hideaki Miyoshi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
- Division of Diabetes and Obesity, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
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18
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Charbit J, Berkane N, Sal M, Bihan H. [Central diabetes insipidus]. Rev Prat 2022; 72:431-436. [PMID: 35638996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
"Central diabetes insipidus Diabetes insipidus may remain undetected for a long time, the ionogram remaining normal as long as polydipsia compensates for diuresis. In the first place, and by argument of frequency, polyuria should rule out diabetes. Diabetes insipidus is evoked in the presence of an incapacitating polyuro polydipsic syndrome, especially at night. Pituitary MRI eliminate a tumoral or infiltrative cause and confirm a central cause by the disappearance of the physiological t1 hypersignal in the post-pituitary gland. A water restriction test should only be performed in a hospital setting under close supervision. Lifetime hormone replacement therapy is appropriate in situations of pregnancy, risk of dehydration, and signs of overdose must be known by the patient, who must be educated about his or her disease."
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Affiliation(s)
- Judith Charbit
- Service d'endocrinologie, diabétologie, maladies métaboliques, hôpital Avicenne, Bobigny, France
| | - Narimane Berkane
- Service d'endocrinologie, diabétologie, maladies métaboliques, hôpital Avicenne, Bobigny, France
| | - Meriem Sal
- Service d'endocrinologie, diabétologie, maladies métaboliques, hôpital Avicenne, Bobigny, France
| | - Hélène Bihan
- Service d'endocrinologie, diabétologie, maladies métaboliques, hôpital Avicenne, Bobigny, France Laboratoire Éducations et Pratiques de santé, EA 3412, université Sorbonne Paris Nord, France
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19
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Sugawara L, Nakamura T, Ishizuka Y, Maegawa H. A case of central diabetes insipidus due to neurophysin II gene abnormality diagnosed based on a family history of nocturnal enuresis. Endocr J 2022; 69:95-100. [PMID: 34544934 DOI: 10.1507/endocrj.ej21-0187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The etiology of central diabetes insipidus (DI) is classified into (1) idiopathic, (2) familial, and (3) secondary. Of these, familial central diabetes insipidus shows an autosomal dominant inheritance. We herein report a case in which this disease was diagnosed based on a family history of nocturnal enuresis. A 40-year-old man had had symptoms of polydipsia, polyuria and nocturia since childhood and found that his daughter had the same symptoms. Despite reaching nine years old, his daughter's nocturnal enuresis still had not improved, resulting in her consulting a pediatrician. She was suspected of having familial neurohypophyseal diabetes insipidus (FNDI) based on her family history and was referred along with her father for a detailed examination and treatment. A hypertonic saline load test (HSLT) to evaluate the arginine vasopressin (AVP) reaction was performed in both the proband and his daughter. The results showed no increase in AVP levels in response to high plasma osmolality. The water deprivation test (WDT) revealed he was suffering from partial DI. Based on the above findings and considering the possibility of familial central diabetes insipidus, we performed a gene mutation analysis of AVP-neurophysin II (NPII). Both the father and daughter had an exon 2 abnormality in this gene (c232_234delGAG; pGlu78del), and this gene mutation is known to cause NPII protein abnormality, abolishing the function of AVP as a carrier protein. This case was considered to have provided an opportunity to understand the role of an NPII gene abnormality in familial central diabetes insipidus.
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Affiliation(s)
- Lucia Sugawara
- Department of Endocrinology and Metabolism, Omihachiman Community Medical Center, Omihachiman, Shiga 523-0082, Japan
- Department of Medicine, Shiga University of Medical Science, Otsu, Shiga 520-2092, Japan
| | - Takaaki Nakamura
- Department of Endocrinology and Metabolism, Omihachiman Community Medical Center, Omihachiman, Shiga 523-0082, Japan
| | - Yoshitaka Ishizuka
- Department of Endocrinology and Metabolism, Omihachiman Community Medical Center, Omihachiman, Shiga 523-0082, Japan
| | - Hiroshi Maegawa
- Department of Medicine, Shiga University of Medical Science, Otsu, Shiga 520-2092, Japan
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Hinata Y, Ohara N, Komatsu T, Sakurai Y, Yoneoka Y, Seki Y, Akiyama K, Sone H. Central Diabetes Insipidus after Syndrome of Inappropriate Antidiuretic Hormone Secretion with Severe Hyponatremia in a Patient with Rathke's Cleft Cyst. Intern Med 2022; 61:197-203. [PMID: 34248116 PMCID: PMC8851191 DOI: 10.2169/internalmedicine.6608-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A 49-year-old man developed severe hyponatremia associated with transient headache and was diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Fluid restriction and sodium supplementation corrected the hyponatremia. However, several days later, the patient exhibited hypernatremia with thirst and polyuria. A detailed examination indicated central diabetes insipidus (CDI) with an intrasellar cystic lesion indicative of Rathke's cleft cyst (RCC). A case of RCC exhibiting headache, hyponatremia, and subsequent hypernatremia has been reported. Our case shows that CDI may appear after SIADH in patients with RCC, especially in those with serum sodium levels that unexpectedly increase rapidly beyond the reference range.
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Affiliation(s)
- Yudai Hinata
- Department of Endocrinology and Metabolism, Uonuma Kikan Hospital, Japan
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Japan
| | - Nobumasa Ohara
- Department of Endocrinology and Metabolism, Uonuma Kikan Hospital, Japan
| | - Takeshi Komatsu
- Department of Endocrinology and Metabolism, Uonuma Kikan Hospital, Japan
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Japan
| | - Yuki Sakurai
- Department of Endocrinology and Metabolism, Uonuma Kikan Hospital, Japan
| | | | - Yasuhiro Seki
- Department of Neurosurgery, Uonuma Kikan Hospital, Japan
| | | | - Hirohito Sone
- Department of Hematology, Endocrinology and Metabolism, Niigata University Faculty of Medicine, Japan
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21
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Astafyeva LI, Sidneva YG, Badmaeva IN, Kalinin PL, Latyshev YA, Marshintsev AV, Valiullina SA. Permanent central diabetes insipidus after traumatic brain injury. Case report and literature review. Zh Vopr Neirokhir Im N N Burdenko 2022; 86:112-118. [PMID: 36252201 DOI: 10.17116/neiro202286051112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The authors report permanent central diabetes insipidus (CDI) in a patient after severe traumatic brain injury (TBI) in traffic accident. A 16-year-old boy entered to a medical facility in coma (GCS score 6) with the following diagnosis: acute TBI, severe cerebral contusion, subarachnoid hemorrhage, depressed comminuted cranial vault fracture, basilar skull fracture, visceral contusion. CDI was diagnosed in 3 days after injury considering polyuria and hypernatremia (155 mmol/l). Desmopressin therapy was initiated through a feeding tube. Thirst appeared when a patient came out of the coma after 21 days despite ongoing desmopressin therapy. Considering persistent thirst and polyuria, we continued desmopressin therapy in a spray form. Under this therapy, polyuria reduced to 3-3.5 liters per a day. Symptoms of CDI persisted in long-term period (2 years after TBI) while function of adenohypophysis was intact. This case demonstrates a rare development of permanent diabetes insipidus after TBI. CDI manifested only as polyuria and hypernatremia in coma. Thirst joined after recovery of consciousness. Probable causes of CDI were damage to neurohypophysis and partially injury of pituitary stalk because of extended basilar skull fracture and/or irreversible secondary lesion of hypothalamus following diffuse axonal damage after TBI.
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Affiliation(s)
| | - Yu G Sidneva
- Burdenko Neurosurgical Center, Moscow, Russia
- Research Institute of Emergency Pediatric Surgery and Traumatology, Moscow, Russia
| | | | - P L Kalinin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - A V Marshintsev
- Research Institute of Emergency Pediatric Surgery and Traumatology, Moscow, Russia
| | - S A Valiullina
- Research Institute of Emergency Pediatric Surgery and Traumatology, Moscow, Russia
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22
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Jameel PZ, Lohiya S, Vagha K, Ahmed T, Pujari D, Vagha J, Varma A. Concurrent central diabetes insipidus and cerebral salt wasting disease in a post-operative case of craniopharyngioma: a case report. BMC Pediatr 2021; 21:502. [PMID: 34758770 PMCID: PMC8579628 DOI: 10.1186/s12887-021-02982-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Water and electrolyte disorders commonly encountered in children post-surgery involving hypothalamus and posterior pituitary, are central diabetes insipidus, syndrome of inappropriate secretion of anti-diuretic hormone and cerebral salt wasting disease. Delayed diagnosis and inadequate management of such cases may lead to worsened neurological outcomes with a high mortality rate. CASE PRESENTATION Here we report the case of a 7-year-old girl who underwent surgical resection of a craniopharyngioma, following which she initially developed central diabetes insipidus. However, later on in the course of her illness she developed symptomatic hyponatremia with natriuresis which was diagnosed to be due to cerebral salt wasting disease. This combination of central diabetes insipidus and cerebral salt wasting syndrome is a rare occurrence and poses a diagnostic challenge. Diagnosis and management can be even more difficult when these conditions precede or coexist with each other. CONCLUSION In such cases development of hyponatremia should always prompt consideration of unusual causes like cerebral salt wasting disease in addition to the classically described syndrome of inappropriate secretion of anti-diuretic hormone. Hence, a thorough knowledge of these disorders along with intensive monitoring of fluid and sodium status is critical for timely diagnosis and management of these patients.
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Affiliation(s)
- Patel Zeeshan Jameel
- Department of Paediatrics, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, 442001, India.
| | - Sham Lohiya
- Department of Paediatrics, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, 442001, India
| | - Keta Vagha
- Department of Paediatrics, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, 442001, India
| | - Tauheed Ahmed
- Department of Medicine, Tata Main Hospital, Jamshedpur, Jharkhand, India
| | - Divya Pujari
- Division of Paediatric Endocrinology, Department of Paediatrics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Jayant Vagha
- Department of Paediatrics, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, 442001, India
| | - Ashish Varma
- Department of Paediatrics, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, 442001, India
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Zhang W, Shen Y, Ren Y, Xin Y, Wang L. Congenital nephrogenic diabetes insipidus accompanied with central nephrogenic diabetes secondary to pituitary surgery -a case report. BMC Endocr Disord 2021; 21:78. [PMID: 33882907 PMCID: PMC8061024 DOI: 10.1186/s12902-021-00749-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 04/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetes insipidus (DI) can be a common cause of polydipsia and polyuria. Here, we present a case of congenital nephrogenic diabetes insipidus (CNDI) accompanied with central diabetes insipidus (CDI) secondary to pituitary surgery. CASE PRESENTATION A 24-year-old Chinese woman came to our hospital with the complaints of polydipsia and polyuria for 6 months. Six months ago, she was detected with pituitary apoplexy, and thereby getting pituitary surgery. However, the water deprivation test demonstrated no significant changes in urine volume and urine gravity in response to fluid depression or AVP administration. In addition, the genetic results confirmed a heterozygous mutation in arginine vasopressin receptor type 2 (AVPR2) genes. CONCLUSIONS She was considered with CNDI as well as acquired CDI secondary to pituitary surgery. She was given with hydrochlorothiazide (HCTZ) 25 mg twice a day as well as desmopressin (DDAVP, Minirin) 0.1 mg three times a day. There is no recurrence of polyuria or polydipsia observed for more than 6 months. It can be hard to consider AVPR2 mutation in female carriers, especially in those with subtle clinical presentation. Hence, direct detection of DNA sequencing with AVPR2 is a convenient and accurate method in CNDI diagnosis.
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Affiliation(s)
- Wei Zhang
- Department of Endocrinology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310003, Zhejiang province, China
- Key Laboratory of Endocrine Gland Diseases of Zhejiang Province, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310003, Zhejiang province, China
| | - Yimin Shen
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, Zhejiang province, China
| | - Yuezhong Ren
- Department of Endocrinology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, Zhejiang province, China
| | - Yvbo Xin
- Department of Endocrinology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310003, Zhejiang province, China
- Key Laboratory of Endocrine Gland Diseases of Zhejiang Province, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310003, Zhejiang province, China
| | - Lijun Wang
- Department of Endocrinology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310003, Zhejiang province, China.
- Key Laboratory of Endocrine Gland Diseases of Zhejiang Province, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310003, Zhejiang province, China.
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24
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Tanaka S, Hirabayashi T, Kimoto M, Hama M, Hachiya T, Gomi K. Gefitinib Treatment Was Unsuccessful for Central Diabetes Insipidus Due to Pituitary Metastasis of Lung Adenocarcinoma. Intern Med 2021; 60:1073-1076. [PMID: 33162476 PMCID: PMC8079922 DOI: 10.2169/internalmedicine.5643-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We herein report a rare case of advanced lung adenocarcinoma with central diabetes insipidus due to pituitary metastasis. Although treatment with gefitinib was dramatically effective, the symptoms of diabetes insipidus did not improve. Radiotherapy for pituitary metastasis was effective to control diabetes insipidus; however, we could not cease the administration of 1-deamino-8-D-arginine vasopressin (DDAVP). It is important for physicians to positively consider radiotherapy for pituitary metastases even if favorable tumor control is achieved with chemotherapy when diabetes insipidus becomes clinically overt. Furthermore, continuous DDAVP administration may be needed to treat central diabetes insipidus.
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Affiliation(s)
- Shunnosuke Tanaka
- Department of Respiratory Medicine, Japanese Red Cross Society Suwa Hospital, Japan
| | - Taro Hirabayashi
- Department of Respiratory Medicine, Japanese Red Cross Society Suwa Hospital, Japan
| | - Masanobu Kimoto
- Department of Respiratory Medicine, Japanese Red Cross Society Suwa Hospital, Japan
| | - Mineyuki Hama
- Department of Respiratory Medicine, Japanese Red Cross Society Suwa Hospital, Japan
| | - Tsutomu Hachiya
- Department of Respiratory Medicine, Japanese Red Cross Society Suwa Hospital, Japan
| | - Kotaro Gomi
- Department of Radiation Oncology, Japanese Red Cross Society Suwa Hospital, Japan
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25
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Niri T, Horie I, Kawahara H, Ando T, Fukuhara N, Nishioka H, Inoshita N, Fujisawa H, Suzuki A, Sugimura Y, Abiru N, Kawakami A. A case of isolated hypothalamitis with a literature review and a comparison with autoimmune hypophysitis. Endocr J 2021; 68:119-127. [PMID: 32963149 DOI: 10.1507/endocrj.ej20-0300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Idiopathic hypothalamitis is a rare condition that can cause anterior pituitary dysfunction and central diabetes insipidus (CDI), occasionally accompanied by a disturbance of autonomic regulation known as hypothalamic syndrome. This condition has been described as a subtype of autoimmune (lymphocytic) hypophysitis; however, some cases of isolated hypothalamic involvement with no inflammatory lesions in either the pituitary gland or infundibulum have been reported. The detailed epidemiology and pathophysiology of isolated hypothalamitis have not been clarified. We herein report a case of a solitary hypothalamic lesion in a young woman who showed spontaneous development of CDI and panhypopituitarism accompanied by hyperphagia. The hypothalamic lesion increased from 11 × 7 to 17 × 7 mm over 16 months based on the sagittal slices of magnetic resonance imaging examinations. The negative results for anti-pituitary antibodies and anti-Rabphilin-3A antibodies suggested that upward extension of lymphocytic adenohypophysitis or infundibulo-neurohypophysitis was unlikely. Infectious disease, granulomatosis, Langerhans cell histiocytosis, vasculitis, and systemic neoplastic diseases were excluded by the findings of a laboratory investigation, cerebrospinal fluid examination, and imaging studies. To make a definitive diagnosis, we performed a ventriculoscopic biopsy of the hypothalamic lesion. Histology revealed an infiltration of nonspecific lymphoplasmacytes with no evidence of neoplasm, which was consistent with a diagnosis of idiopathic hypothalamitis. Subsequently, the patient was treated with methylprednisolone pulse therapy followed by oral prednisolone. The hypothalamic lesion improved and remained undetectable after withdrawal of the prednisolone, suggesting that the glucocorticoid treatment was effective for isolated hypothalamitis while the patient remains dependent on the replacement of multiple hormones.
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Affiliation(s)
- Tetsuro Niri
- Department of Endocrinology and Metabolism, Nagasaki University Hospital, Nagasaki, Japan
| | - Ichiro Horie
- Department of Endocrinology and Metabolism, Nagasaki University Hospital, Nagasaki, Japan
| | - Hiromi Kawahara
- Department of Endocrinology and Metabolism, Nagasaki University Hospital, Nagasaki, Japan
| | - Takao Ando
- Department of Endocrinology and Metabolism, Nagasaki University Hospital, Nagasaki, Japan
| | - Noriaki Fukuhara
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo, Japan
| | - Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo, Japan
| | - Naoko Inoshita
- Department of Pathology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Haruki Fujisawa
- Department of Endocrinology and Metabolism, Fujita Health University, Toyoake, Japan
| | - Atsushi Suzuki
- Department of Endocrinology and Metabolism, Fujita Health University, Toyoake, Japan
| | - Yoshihisa Sugimura
- Department of Endocrinology and Metabolism, Fujita Health University, Toyoake, Japan
| | - Norio Abiru
- Department of Endocrinology and Metabolism, Nagasaki University Hospital, Nagasaki, Japan
| | - Atsushi Kawakami
- Department of Endocrinology and Metabolism, Nagasaki University Hospital, Nagasaki, Japan
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26
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Türe U, De Bellis A, Harput MV, Bellastella G, Topcuoglu M, Yaltirik CK, Cirillo P, Yola RN, Sav A, Kelestimur F. Hypothalamitis: A Novel Autoimmune Endocrine Disease. A Literature Review and Case Report. J Clin Endocrinol Metab 2021; 106:e415-e429. [PMID: 33104773 DOI: 10.1210/clinem/dgaa771] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Indexed: 12/18/2022]
Abstract
CONTEXT The relationship between the endocrine system and autoimmunity has been recognized for a long time and one of the best examples of autoimmune endocrine disease is autoimmune hypophysitis. A better understanding of autoimmune mechanisms and radiological, biochemical, and immunological developments has given rise to the definition of new autoimmune disorders including autoimmunity-related hypothalamic-pituitary disorders. However, whether hypothalamitis may occur as a distinct entity is still a matter of debate. EVIDENCE ACQUISITION Here we describe a 35-year-old woman with growing suprasellar mass, partial empty sella, central diabetes insipidus, hypopituitarism, and hyperprolactinemia. EVIDENCE SYNTHESIS Histopathologic examination of surgically removed suprasellar mass revealed lymphocytic infiltrate suggestive of an autoimmune disease with hypothalamic involvement. The presence of antihypothalamus antibodies to arginine vasopressin (AVP)-secreting cells (AVPcAb) at high titers and the absence of antipituitary antibodies suggested the diagnosis of isolated hypothalamitis. Some similar conditions have sometimes been reported in the literature but the simultaneous double finding of lymphocytic infiltrate and the presence of AVPcAb so far has never been reported. CONCLUSIONS We think that the hypothalamitis can be considered a new isolated autoimmune disease affecting the hypothalamus while the lymphocytic infundibuloneurohypophysitis can be a consequence of hypothalamitis with subsequent autoimmune involvement of the pituitary. To our knowledge this is the first observation of autoimmune hypothalamic involvement with central diabetes insipidus, partial empty sella, antihypothalamic antibodies and hypopituitarism.
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Affiliation(s)
- Uğur Türe
- Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Annamaria De Bellis
- Unit of Endocrinology and Metabolic Diseases, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Mehmet Volkan Harput
- Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Giuseppe Bellastella
- Unit of Endocrinology and Metabolic Diseases, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Melih Topcuoglu
- Department of Radiology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Cumhur Kaan Yaltirik
- Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Paolo Cirillo
- Unit of Endocrinology and Metabolic Diseases, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Rima Nur Yola
- Medical Student, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Aydın Sav
- Department of Pathology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Fahrettin Kelestimur
- Department of Endocrinology, Yeditepe University School of Medicine, Istanbul, Turkey
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27
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Kim F, Towers HM. Management of transient central diabetes insipidus with intravenous desmopressin in a premature infant with gastroschisis and septo-optic dysplasia: A case report. J Neonatal Perinatal Med 2021; 14:293-297. [PMID: 32804104 DOI: 10.3233/npm-200465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Central diabetes insipidus (CDI) may occur in the setting of intracranial abnormalities that affect the hypothalamus-pituitary system. It occurs rarely in neonates, especially in the premature population, and represents a challenging disease process to treat pharmacologically. Little is known regarding the treatment options in premature infants, including dose and route of administration of intravenous desmopressin (DDAVP). We present a case of a late premature male infant with gastroschisis and septo-optic dysplasia who developed transient CDI. He was treated with intravenous DDAVP but required frequent laboratory monitoring and a multidisciplinary approach, and ultimately his CDI resolved. Although there are minimal guidelines regarding the appropriate formulation and dosage of DDAVP for management of CDI in infants, we initiated the lowest dose available and titrated the medication based on close monitoring of urine output and serum sodium levels in order to successfully treat his transient CDI.
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Affiliation(s)
- Faith Kim
- Department of Pediatrics, Division of Neonatology, Columbia University Medical Center/NewYork-Presbyterian Morgan Stanley Children's Hospital of New York, New York City, NY, USA
| | - Helen M Towers
- Department of Pediatrics, Division of Neonatology, Columbia University Medical Center/NewYork-Presbyterian Morgan Stanley Children's Hospital of New York, New York City, NY, USA
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28
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Abstract
Once central diabetes insipidus (CDI) has been diagnosed, every effort should be made to reveal its underlying cause. Autoimmune CDI should be considered in the differential diagnosis of idiopathic CDI and also of mass lesions of the sella region. An autoimmune etiology of CDI was first suggested in 1983 by the detection of autoantibodies to hypothalamic vasopressin-producing cells (AVPcAb) in adults and also in children with the disease, using the indirect immunofluorescence test. The major autoantigen for autoimmune CDI has now been recognized as rabphilin-3A, a protein of secretory vesicles of the neurohypophyseal system. The detection of autoantibodies to rabphilin-3A by Western blotting or of AVPcAb provides strong evidence for the diagnosis of autoimmune CDI. Autoimmune CDI is recognized mostly in patients who had also been diagnosed with endocrine autoimmune disorders. The radiological and morphological correlate with autoimmune DI is lymphocytic infundibuloneurohypophysitis (LINH) as detected by magnetic resonance imaging and biopsies that show massive infiltration of the posterior pituitary and the infundibulum with lymphocytes and some plasma cells, and fibrosis in the later stages of the disease. LINH may be associated with lymphocytic anterior hypophysitis. Both may either appear spontaneously or on treatment with immune checkpoint inhibitors.
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Affiliation(s)
- Werner A Scherbaum
- Department of Endocrinology, Heinrich-Heine-University, Duesseldorf, Germany.
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29
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Hussain A, Baier RJ, Mehrem AA, Soylu H, Fraser D, Elsayed Y. Central Diabetes Insipidus in a Preterm Neonate Unresponsive to Intranasal Desmopressin. Neonatal Netw 2020; 39:339-346. [PMID: 33318230 DOI: 10.1891/0730-0832/11-t-679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2020] [Indexed: 06/12/2023]
Abstract
Central or neurogenic diabetes insipidus (DI) is uncommon in the pediatric age group and rarely occurs in neonates. It should be suspected in any neonate presenting with excessive urine output and hypernatremia that persists despite increased fluid administration. Diabetes insipidus may be secondary to asphyxia, intraventricular hemorrhage, infection, and structural abnormalities or may be idiopathic or genetic. Diagnosis includes a careful history, laboratory testing, and magnetic resonance imaging. Management of neonatal DI involves a careful balance between fluid intake and pharmacologic treatment. In this article we report a case of an extremely low birth weight infant presenting with central DI possibly caused by abnormality of the pituitary gland. Persistent hypernatremia was the initial presentation. Increased fluids were given initially but were only partially helpful. Eventually subcutaneous desmopressin (DDAVP) was required. The infant was unresponsive to intranasal DDAVP and required subcutaneous DDAVP upon discharge.
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30
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Abstract
Central diabetes insipidus (CDI) is a complex disorder in which large volumes of dilute urine are excreted due to arginine-vasopressin deficiency, and it is caused by a variety of conditions (genetic, congenital, inflammatory, neoplastic, traumatic) that arise mainly from the hypothalamus. The differential diagnosis between diseases presenting with polyuria and polydipsia is challenging and requires a detailed medical history, physical examination, biochemical approach, imaging studies and, in some cases, histological confirmation. Magnetic resonance imaging is the gold standard method for evaluating the sellar-suprasellar region in CDI. Pituitary stalk size at presentation is variable and can change over time, depending on the underlying condition, and other brain areas or other organs - in specific diseases - may become involved during follow up. An early diagnosis and treatment are preferable in order to avoid central nervous system damage and the risk of dissemination of germ cell tumor, or progression of Langerhans Cell Histiocytosis, and in order to start treatment of additional pituitary defects without further delay. This review focuses on current diagnostic work-up and on the role of neuroimaging in the differential diagnosis of CDI in children and adolescents. It provides an update on the best approach for diagnosis - including novel biochemical markers such as copeptin - treatment and follow up of children and adolescents with CDI; it also describes the best approach to challenging situations such as post-surgical patients, adipsic patients, patients undergoing chemotherapy and/or in critical care.
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MESH Headings
- Adolescent
- Age of Onset
- Biomarkers/analysis
- Brain/diagnostic imaging
- Brain/pathology
- Child
- Diabetes Insipidus, Neurogenic/diagnosis
- Diabetes Insipidus, Neurogenic/epidemiology
- Diabetes Insipidus, Neurogenic/etiology
- Diabetes Insipidus, Neurogenic/therapy
- Diagnosis, Differential
- Diagnostic Imaging/methods
- Diagnostic Imaging/trends
- Diagnostic Techniques, Endocrine/trends
- Histiocytosis, Langerhans-Cell/complications
- Histiocytosis, Langerhans-Cell/diagnosis
- Histiocytosis, Langerhans-Cell/epidemiology
- Histiocytosis, Langerhans-Cell/therapy
- Humans
- Magnetic Resonance Imaging
- Polydipsia/diagnosis
- Polydipsia/epidemiology
- Polydipsia/etiology
- Polydipsia/therapy
- Polyuria/diagnosis
- Polyuria/epidemiology
- Polyuria/etiology
- Polyuria/therapy
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Affiliation(s)
- Giuseppa Patti
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, Genova, Italy; Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Anastasia Ibba
- SSD Endocrinologia Pediatrica, Ospedale Pediatrico Microcitemico "A. Cao", AO Brotzu, Cagliari, Italy
| | - Giovanni Morana
- Department of Neurosciences, University of Turin, Turin, Italy; Department of Neuroradiology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Flavia Napoli
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Daniela Fava
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, Genova, Italy; Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Natascia di Iorgi
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, Genova, Italy; Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Mohamad Maghnie
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, Genova, Italy; Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy.
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31
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Abstract
Most cases of acquired central diabetes insipidus are caused by destruction of the neurohypophysis by: 1) anatomic lesions that destroy the vasopressin neurons by pressure or infiltration, 2) damage to the vasopressin neurons by surgery or head trauma, and 3) autoimmune destruction of the vasopressin neurons. Because the vasopressin neurons are located in the hypothalamus, lesions confined to the sella turcica generally do not cause diabetes insipidus because the posterior pituitary is simply the site of the axon terminals that secrete vasopressin into the bloodstream. In addition, the capacity of the neurohypophysis to synthesize vasopressin is greatly in excess of the body's needs, and destruction of 80-90% of the hypothalamic vasopressin neurons is required to produce diabetes insipidus. As a result, even large lesions in the sellar and suprasellar area generally are not associated with impaired water homeostasis until they are surgically resected. Regardless of the etiology of central diabetes insipidus, deficient or absent vasopressin secretion causes impaired urine concentration with resultant polyuria. In most cases, secondary polydipsia is able to maintain water homeostasis at the expense of frequent thirst and drinking. However, destruction of the osmoreceptors in the anterior hypothalamus that regulate vasopressin neuronal activity causes a loss of thirst as well as vasopressin section, leading to severe chronic dehydration and hyperosmolality. Vasopressin deficiency also leads to down-regulation of the synthesis of aquaporin-2 water channels in the kidney collecting duct principal cells, causing a secondary nephrogenic diabetes insipidus. As a result, several days of vasopressin administration are required to achieve maximal urine concentration in patients with CDI. Consequently, the presentation of patients with central diabetes insipidus can vary greatly, depending on the size and location of the lesion, the magnitude of trauma to the neurohypophysis, the degree of destruction of the vasopressin neurons, and the presence of other hormonal deficits from damage to the anterior pituitary.
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MESH Headings
- Aquaporin 2/metabolism
- Brain Injuries, Traumatic/complications
- Brain Injuries, Traumatic/diagnosis
- Brain Injuries, Traumatic/epidemiology
- Brain Injuries, Traumatic/therapy
- Diabetes Insipidus, Nephrogenic/etiology
- Diabetes Insipidus, Nephrogenic/metabolism
- Diabetes Insipidus, Neurogenic/diagnosis
- Diabetes Insipidus, Neurogenic/epidemiology
- Diabetes Insipidus, Neurogenic/etiology
- Diabetes Insipidus, Neurogenic/therapy
- Homeostasis/physiology
- Humans
- Neurophysins/physiology
- Pituitary Diseases/complications
- Pituitary Diseases/diagnosis
- Pituitary Diseases/epidemiology
- Pituitary Diseases/therapy
- Pituitary Gland, Posterior/pathology
- Polydipsia/diagnosis
- Polydipsia/epidemiology
- Polydipsia/etiology
- Polydipsia/therapy
- Polyuria/diagnosis
- Polyuria/epidemiology
- Polyuria/etiology
- Polyuria/therapy
- Protein Precursors/physiology
- Vasopressins/physiology
- Water-Electrolyte Balance/physiology
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32
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Abstract
In the pregnant patient, hypotonic polyuria in the setting of elevated serum osmolality and polydipsia should narrow the differential to causes related to diabetes insipidus (DI). Gestational DI, also called transient DI of pregnancy, is a distinct entity, unique from central DI or nephrogenic DI which may both become exacerbated during pregnancy. These three different processes relate to vasopressin, where increased metabolism, decreased production or altered renal sensitivity to this neuropeptide should be considered. Gestational DI involves progressively rising levels of placental vasopressinase throughout pregnancy, resulting in decreased endogenous vasopressin and resulting hypotonic polyuria worsening through the pregnancy. Gestational DI should be distinguished from central and nephrogenic DI that may be seen during pregnancy through use of clinical history, urine and serum osmolality measurements, response to desmopressin and potentially, the newer, emerging copeptin measurement. This review focuses on a brief overview of osmoregulatory and vasopressin physiology in pregnancy and how this relates to the clinical presentation, pathophysiology, diagnosis and management of gestational DI, with comparisons to the other forms of DI during pregnancy. Differentiating the subtypes of DI during pregnancy is critical in order to provide optimal management of DI in pregnancy and avoid dehydration and hypernatremia in this vulnerable population.
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Affiliation(s)
- Sonia Ananthakrishnan
- Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine/Boston Medical Center, 72 Concord Street, Evans 122, Boston, MA, 02118, United States.
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33
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Abstract
The two main differential diagnoses of central diabetes insipidus are nephrogenic diabetes insipidus and primary polydipsia. Reliable distinction between those entities is essential as treatment differs substantially with the wrong treatment potentially leading to serious complications. Past diagnostic measures using the indirect water deprivation test had several pitfalls, resulting in a low diagnostic accuracy. With the introduction of copeptin, a stable and reliable surrogate marker for arginine vasopressin, diagnosis of diabetes insipidus was new evaluated. While unstimulated basal copeptin measurement reliably diagnoses nephrogenic diabetes insipidus, a stimulation test is needed to differentiate patients with central diabetes insipidus from patients with primary polydipsia. Stimulation can either be achieved through hypertonic saline infusion or arginine infusion. While the former showed high diagnostic accuracy and superiority over the indirect water deprivation test in a recent validation study, the diagnostic accuracy for arginine-stimulated copeptin was slightly lower, but superior in test tolerance. In summary of the recent findings, a new copeptin based diagnostic algorithm is proposed for the reliable diagnosis of diabetes insipidus.
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Affiliation(s)
- Julie Refardt
- Departments of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Switzerland; University of Basel, Basel, Switzerland.
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34
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Abstract
In the majority of cases, hereditary neurohypophyseal diabetes insipidus (DI) is a monogenic disorder caused by mutations in the AVP gene. Dominant transmission is by far the most common form. In these patients, symptoms develop gradually at various ages during childhood, progressing with complete penetrance to polyuria and polydipsia that is usually severe. In autosomal dominant neurohypophyseal DI (ADNDI), the mutant prohormone is folding deficient and consequently retained in the ER, where it forms amyloid-like fibrillar aggregates. Degradation by proteasomes occurs, but their clearance capacity appears to be insufficient. Postmortem studies in affected individuals suggest a neurodegenerative process confined to vasopressinergic neurons. Other forms of genetic neurohypophyseal DI include the very rare autosomal recessive type, also caused by mutations in the AVP gene, and complex multiorgan disorders, such as Wolfram syndrome. In all individuals where a congenital form of DI is suspected, including nephrogenic types, genetic analysis should be performed.
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Affiliation(s)
- Martin Spiess
- University of Basel, Biozentrum, Klingelbergstrasse 50/70, CH-4056 Basel, Switzerland.
| | - Nicole Beuret
- University of Basel, Biozentrum, Klingelbergstrasse 50/70, CH-4056 Basel, Switzerland.
| | - Jonas Rutishauser
- University of Basel, Biozentrum, Klingelbergstrasse 50/70, CH-4056 Basel, Switzerland; Kantonsspital Baden, Clinical Trial Unit, Im Ergel 1, CH-5405 Baden, Switzerland.
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35
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Takagi H, Hagiwara D, Handa T, Sugiyama M, Onoue T, Tsunekawa T, Ito Y, Iwama S, Goto M, Suga H, Banno R, Takahashi K, Matsui S, Arima H. Diagnosis of central diabetes insipidus using a vasopressin radioimmunoassay during hypertonic saline infusion. Endocr J 2020; 67:267-274. [PMID: 31748430 DOI: 10.1507/endocrj.ej19-0224] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Central diabetes insipidus (CDI) is characterized by polyuria and polydipsia caused by impairment of arginine vasopressin (AVP) secretion. In this study, we evaluated plasma AVP concentrations during a hypertonic saline infusion test using a new AVP radioimmunoassay (RIA) which is now available in Japan. Thirteen control subjects, mostly with hypothalamo-pituitary disease but without CDI, and 13 patients with CDI were enrolled in the study. Whether or not subjects had CDI was determined based on the totality of clinical data, which included urine volumes and osmolality. Regression analysis of plasma AVP and serum Na concentrations revealed that the gradient was significantly lower in the CDI group than in the control group. The area under the receiver-operating-characteristic (ROC) curve was 0.99, and the <0.1 gradient cut-off values for the simple regression line to distinguish CDI from control had a 100% sensitivity and a 77% specificity. The ROC analysis with estimated plasma AVP concentrations at a serum Na concentration of 149 mEq/L showed that the area under the ROC curve was 1.0 and the <1.0 pg/mL cut-off values of plasma AVP had a 99% sensitivity and a 95% specificity. We conclude that measurement of AVP by RIA during a hypertonic saline infusion test can differentiate patients with CDI from those without CDI with a high degree of accuracy. Further investigation is required to confirm whether the cut-off values shown in this study are also applicable to a diagnosis of partial CDI or a differential diagnosis between CDI and primary polydipsia.
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Affiliation(s)
- Hiroshi Takagi
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Daisuke Hagiwara
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Tomoko Handa
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Mariko Sugiyama
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Takeshi Onoue
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Taku Tsunekawa
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Yoshihiro Ito
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Shintaro Iwama
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Motomitsu Goto
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Hidetaka Suga
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Ryoichi Banno
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Kunihiko Takahashi
- Department of Biological Statistics, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Shigeyuki Matsui
- Department of Biological Statistics, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Hiroshi Arima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
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Berton AM, Gatti F, Penner F, Varaldo E, Prencipe N, Rumbolo F, Settanni F, Gasco V, Ghigo E, Zenga F, Grottoli S. Early Copeptin Determination Allows Prompt Diagnosis of Post-Neurosurgical Central Diabetes Insipidus. Neuroendocrinology 2020; 110:525-534. [PMID: 31484187 DOI: 10.1159/000503145] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/02/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Central diabetes insipidus (CDI) is a frequent complication of pituitary surgery, but its diagnosis lacks standardized criteria. Copeptin, a surrogate marker of arginine vasopressin release, is triggered by psycho-physical stresses such as pituitary surgery. Low postoperative copeptin could predict CDI onset. The aims of this study were the validation of copeptin as a predictor of post-neurosurgical CDI and the identification of the optimal timing for its determination. METHODS Sixty-six consecutive patients operated for a hypothalamic-pituitary lesion were evaluated. Copeptin was determined preoperatively and at 1, 6, 12, 24 and 48 h post-extubation. Fifty-eight patients were reassessed after 3-6 months post-surgery to confirm transient (3 cases) or permanent CDI (5 cases) diagnosis. RESULTS A marked copeptin peak was identified at 1 h after extubation, when a value below or equal to 12.8 pmol/L had a good accuracy in identifying CDI cases (AUC 0.866, 95% CI 0.751-0.941). Moreover, a copeptin peak above 4.2 pmol/L excluded permanent forms (AUC 1, 95% CI 0.629-1). Regression analysis identified copeptin as the only significant predictor of CDI (OR 0.86, 95% CI 0.75-0.98, p = 0.02). A copeptin T1/T0 ratio below or equal to 1.47 identified patients at risk of isolated biochemical alterations even in the absence of an overt CDI. CONCLUSIONS A prompt increase of copeptin is expected at 1 h after extubation. The absence of this peak is a reliable predictor of post-neurosurgical CDI.
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Affiliation(s)
- Alessandro Maria Berton
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Science, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy,
| | - Filippo Gatti
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Science, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
| | - Federica Penner
- Division of Neurosurgery, Department of Neuroscience and Mental Health, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
| | - Emanuele Varaldo
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Science, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
| | - Nunzia Prencipe
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Science, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
| | - Francesca Rumbolo
- Laboratory of Endocrinology, Diabetology and Metabolism, Department of Medical Science, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
| | - Fabio Settanni
- Laboratory of Endocrinology, Diabetology and Metabolism, Department of Medical Science, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
| | - Valentina Gasco
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Science, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
| | - Ezio Ghigo
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Science, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
| | - Francesco Zenga
- Division of Neurosurgery, Department of Neuroscience and Mental Health, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
| | - Silvia Grottoli
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Science, University Hospital "Città della Salute e della Scienza di Torino", Turin, Italy
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Abstract
Diabetes insipidus (DI), be it from central or from nephrogenic origin, has to be differentiated from primary polydipsia. This differentiation is crucial since wrong treatment can have dangerous consequences. For decades, the "gold standard" for differential diagnosis has been the standard water deprivation test. However, this test has several limitations leading to an overall limited diagnostic accuracy. In addition, the test has a long duration of 17 h and is cumbersome for patients. Also clinical signs and symptoms and MRI characteristics overlap between patients with DI and primary polydipsia. Direct measurement of arginine vasopressin (AVP) upon osmotic stimulation was first shown to overcome these limitations, but failed to enter clinical practice mainly due to technical limitations of the AVP assay. Copeptin is secreted in equimolar ratio to AVP, mirroring AVP concentrations in the circulation. We have shown that copeptin, without prior fluid deprivation, identifies patients with nephrogenic DI. For the more difficult differentiation between central DI and primary polydipsia, a copeptin level of 4.9 pmol/L stimulated with hypertonic saline infusion differentiates between these 2 entities with a high diagnostic accuracy and is superior to the water deprivation test. However, it is important to note that close and regular sodium monitoring every 30 min during the hypertonic saline test is a prerequisite, which is not possible in all hospitals. Furthermore, side effects are common. Therefore, a nonosmotic stimulation test would be advantageous. Arginine significantly stimulates copeptin and therefore is a novel, so far unknown stimulus of this peptide. Consequently, infusion of arginine with subsequent copeptin measurement was shown to be an even simpler and better tolerated test, but head to head comparison is still lacking.
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Affiliation(s)
- Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism University Hospital Basel, Basel, Switzerland,
- Department of Clinical Research, University of Basel, Basel, Switzerland,
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Abstract
Diabetes insipidus (DI), be it from central or nephrogenic origin, must be differentiated from secondary forms of hypotonic polyuria such as primary polydipsia. Differentiation is crucial since wrong treatment can have deleterious consequences. Since decades, the gold standard for differentiation has been the water deprivation test, which has limitations leading to an overall unsatisfying diagnostic accuracy. Furthermore, it is cumbersome for patients with a long test duration. Clinical signs and symptoms and MRI characteristics overlap between patients with DI and primary polydipsia. The direct test including vasopressin (AVP) measurement upon osmotic stimulation was meant to overcome these limitations, but failed to enter clinical practice mainly due to technical constraints of the AVP assay. Copeptin is secreted in equimolar amount to AVP but can easily be measured with a sandwich immunoassay. A high correlation between copeptin and AVP has been shown. Accordingly, copeptin mirrors the amount of AVP in the circulation and has led to a 'revival' of the direct test in the differential diagnosis of DI. We have shown that a baseline copeptin, without prior thirsting, unequivocally identifies patients with nephrogenic DI. In contrast, for the differentiation between central DI and primary polydipsia, a stimulated copeptin level of 4.9 pmol/L upon hypertonic saline infusion differentiates these two entities with a high diagnostic accuracy and is superior to the water deprivation test. Close sodium monitoring during the test is a prerequisite. Further new test methods are currently evaluated and might provide an even simpler way of differential diagnosis in the future.
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Affiliation(s)
- Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism and Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Correspondence should be addressed to M Christ-Crain;
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Brys ADH, Vermeersch S, Forsyth R, Velkeniers B, Bravenboer B. Central diabetes insipidus: beware of Langerhans cell histiocytosis! Neth J Med 2018; 76:445-449. [PMID: 30569891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Langerhans cell histiocytosis (LCH) is a rare disorder, characterised by a monoclonal proliferation of aberrant histiocytes that accumulate in and infiltrate into different organs. When the hypothalamic-pituitary axis is involved, central diabetes insipidus (CDI) can be its first manifestation. Three cases of LCH with central diabetes insipidus were retrospectively analyzed: Case 1 is a 41-year old female presenting with polyuria and polydipsia. Diabetes insipidus was diagnosed and treated with desmopressin. MRI pituitary showed hypophysitis. Subsequently, she developed bone lesions and a biopsy demonstrated LCH. Case 2 is a 51-year old female presenting in 2009 with polyuria and polydipsia. Diabetes insipidus was diagnosed and treated with desmopressin. MRI pituitary revealed hypophysitis. LCH was suspected because of known pulmonary histiocytosis. Coexisting bone lesions were biopsied and confirmed LCH. Case 3 is a 44-year old female presenting with diabetes insipidus. She was treated with desmopressin as well. MRI of the pituitary gland showed impressive thickening of the infundibulum. A few months later, she developed skin lesions and a biopsy revealed LCH. Conclusively, LCH is a rare, elusive and probably underdiagnosed disease with a broad disease spectrum. Due to infiltration of the hypothalamic-pituitary axis, CDI can be the first manifestation, even before LCH is diagnosed. Therefore, LCH should be considered in the diagnostic workup of CDI.
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Affiliation(s)
- A D H Brys
- Department of Internal Medicine, Maastricht University Medical Centre, the Netherlands
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Barbot M, Ceccato F, Zilio M, Albiger N, Sigon R, Rolma G, Boscaro M, Scaroni C, Bilora F. Cardiovascular autonomic dysfunction in patients with idiopathic diabetes insipidus. Pituitary 2018; 21:50-55. [PMID: 29081004 DOI: 10.1007/s11102-017-0846-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Central diabetes insipidus (DI) is a rare disease characterized by the excretion of excessive volumes of dilute urine due to reduced levels of the antidiuretic hormone arginine vasopressin (AVP), caused by an acquired or genetic defect in the neurohypophysis. The aim of this study was to identify any autonomic dysfunction (AD) in patients with DI as a possible cofactor responsible for their reportedly higher mortality. METHODS The study involved 12 patients (6 females) with central idiopathic DI and a well-controlled electrolyte balance, and 12 controls matched for age, sex and cardiovascular risk factors, who were assessed using the tilt, lying-to-standing, hand grip, deep breath, Valsalva maneuver and Stroop tests. RESULTS The tilt test showed a significantly more pronounced decrease in both systolic (- 20.67 ± 18 vs. - 1.92 ± 6.99 mmHg, p = 0.0009) and diastolic blood pressure (- 10.5 ± 14.29 vs. - 1.5 ± 5 mmHg, p = 0.012) in patients than in controls. Three patients with DI had to suspend the test due to the onset of syncope. The lying-to-standing test also revealed a marked reduction in blood pressure in patients with DI (1.05 ± 0.13 vs. 1.53 ± 0.14, p = 0.0001). Similar results emerged for the Valsalva maneuver (Valsalva ratio, 1.24 ± 0.19 vs. 1.79 ± 0.11, p < 0.0001) and deep breath test (1.08 ± 0.11 vs. 1.33 ± 0.08, p < 0.0001). CONCLUSIONS All the principal autonomic tests performed in the study were concordant in indicating that patients with central DI have an impaired autonomic nervous system function despite a normal hydroelectrolytic balance under desmopressin therapy. This impairment may reflect damage to the autonomic system per se and/or the absence of any vasoactive effect of AVP on vascular smooth muscle. In our opinion, patients with central DI should be educated on how to prevent orthostatic hypotension, and pharmacological treatment should be considered for patients with a more marked impairment.
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Affiliation(s)
- Mattia Barbot
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padova, Italy.
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padova, Italy
| | - Marialuisa Zilio
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padova, Italy
| | - Nora Albiger
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padova, Italy
| | - Riccardo Sigon
- Endocrinology Unit, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Giuseppe Rolma
- Neuroradiology Institute, Hospital of Padova, Padova, Italy
| | - Marco Boscaro
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padova, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padova, Italy
| | - Franca Bilora
- Coagulation Section, Department of Cardiovascular and Thoracic Sciences, University of Padova, Padova, Italy
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Palumbo C, Nicolaci N, La Manna AA, Branek N, Pissano MN. [Association between central diabetes insipidus and type 2 diabetes mellitus]. Medicina (B Aires) 2018; 78:127-130. [PMID: 29659364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023] Open
Abstract
Central diabetes insipidus is a rare disease of the hypothalamus and neurohypophysis. It is very unusually found in the adult with type 2 diabetes mellitus. It is manifested by a polydipsic polyuric syndrome, which must be distinguished from the poorly controlled type 2 diabetes mellitus. Given the similarity of both entities and the unusual nature of their coexistence, their suspicion is difficult. The case of a 72-year-old male with type 2 diabetes mellitus with poor insulin control (fasting hyperglycemia greater than 180 mg/dl) who had a long-standing polyuric syndrome is here presented. Hypernatremia and plasma osmolality elevated together with a low urinary osmolality led to the suspicion of diabetes insipidus, which was subsequently confirmed by the dehydration test and the administration of desmopressin sc. With 61% increase in the calculated urinary osmolarity one hour post desmopressin s.c., diabetes insipidus of central type was diagnosed. Nuclear Magnetic Resonance showed a bright spot with normal neurohypophysis, contributing to the diagnosis of the idiopathic form.
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MESH Headings
- Aged
- Diabetes Insipidus, Neurogenic/blood
- Diabetes Insipidus, Neurogenic/complications
- Diabetes Insipidus, Neurogenic/diagnosis
- Diabetes Insipidus, Neurogenic/urine
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/complications
- Diabetes Mellitus, Type 2/diagnosis
- Diabetes Mellitus, Type 2/urine
- Diagnosis, Differential
- Gadolinium DTPA
- Humans
- Magnetic Resonance Imaging
- Male
- Osmolar Concentration
- Pituitary Gland, Posterior
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Affiliation(s)
- Claudia Palumbo
- Servicio de Nefrología, Clínica Ciudad de la Vida, Buenos Aires, Argentina. E-mail:
| | - Nora Nicolaci
- Servicio de Neurología, Clínica Ciudad de la Vida, Buenos Aires, Argentina
| | - Andrés A La Manna
- Servicio de Terapia Intermedia, Clínica Ciudad de la Vida, Buenos Aires, Argentina
| | - Natalia Branek
- Servicio de Laboratorio, Clínica Ciudad de la Vida, Buenos Aires, Argentina
| | - María N Pissano
- Servicio de Nefrología, Clínica Ciudad de la Vida, Buenos Aires, Argentina
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Hetman M, Fułek M, Zajączkowska K, Żarczyńska A, Łagosz P, Barg E. The central diabetes insipidus associated with septo-optic dysplasia (de Morsier syndrome). Pediatr Endocrinol Diabetes Metab 2018; 24:197-203. [PMID: 30963758 DOI: 10.5114/pedm.2018.83367] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Septo-optic dysplasia (SOD) is a rare congenital heterogeneous malformation with postulated genetic and environmental etiology. Septo-optic dysplasia is characterized by classic triad: optic nerve hypoplasia, midline brain malformation and hypothalamic-pituitary endocrine deficiencies. The most common hormonal deficiencies affect growth hormone and gonadotropin but it can also be lower levels of the other hormones. The rarest form of hormone deficiency is the deficiency of the antidiuretic hormone. CASE REPORT The boy was born in 39th week of pregnancy in general good condition. Weakened suction reflex and spitting resulted in substantial difficulties with breastfeeding. After transfontanelle ultrasonography central nervous system defect was suspected. In the 5th month of life MRI confirmed septo-optic dysplasia on the basis of anterior genu of corpus callosum and septum pellucidum agenesis, both optic nerves and optic chiasm hypoplasia, pachygyria and polimicrogyria of the right frontoparietal cortex. Neurological examination revealed axial laxity, psychomotor development delay, difficulties in keeping eyes fixed as well as rotary and horizontal nystagmus. At the age of 3 years he underwent the endocrinological consultation due to polydipsia and polyuria. The tests revealed lower urine specific gravity tests results, therefore diabetes insipidus was diagnosed. The boy still receives desmopressin and there are no signs of central diabetes insipidus. Currently, the boy is under a multi-disciplinary medical care. CONCLUSIONS The attention should be focussed on early diagnosis, mutli-specialized care and treatment SOD. Hypopituitarism ranges from isolated to multiple hormone deficits, with diabetes insipidus in a minority. Although rare, SOD is an important cause of congenital hypopituitarism and should be considered in all children with midline defects and optic nerve hyploplasia.
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Affiliation(s)
- Marta Hetman
- Students' Science Society, Wroclaw Medical University, Poland
| | - Michał Fułek
- Students' Science Society, Wroclaw Medical University, Poland
| | | | - Anna Żarczyńska
- Students' Science Society, Wroclaw Medical University, Poland
| | - Piotr Łagosz
- Students' Science Society, Wroclaw Medical University, Poland
| | - Ewa Barg
- Chair and Department of Basic Medical Sciences, Wroclaw Medical University, Poland
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Del Carpio-Orantes L. [Transient central diabetes insipidus associated with pregnancy. Case report and bibliography review]. Rev Med Inst Mex Seguro Soc 2017; 55:672-675. [PMID: 29193952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The case of a patient affected by transient diabetes insipidus associated with pregnancy, in the context of eclampsia, which was presented during seizures and identified by polyuria important, as well as changes in the urinary density occurs, and improving after nasal administration of desmopressin, which confirmed the diagnosis and treatment served completely by sending the picture without any sequel.
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Affiliation(s)
- Luis Del Carpio-Orantes
- Departamento de Medicina Interna, Hospital General de Zona No. 71 Instituto Mexicano del Seguro Social, Veracruz, Veracruz, México
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Affiliation(s)
- S Wijetilleka
- From the Department of Endocrinology, Royal Liverpool University Hospital, Liverpool L7 8XP, UK
| | - M Khan
- From the Department of Endocrinology, Royal Liverpool University Hospital, Liverpool L7 8XP, UK
| | - A Mon
- From the Department of Endocrinology, Royal Liverpool University Hospital, Liverpool L7 8XP, UK
| | - D Sharma
- From the Department of Endocrinology, Royal Liverpool University Hospital, Liverpool L7 8XP, UK
| | - F Joseph
- Department of Diabetes and Endocrinology, Countess of Chester NHS Foundation Trust, Chester CH2 1UL, UK
| | | | - K Das
- Department of Neuroradiology, Walton Centre of Neurology and Neurosurgery, Liverpool L9 7LJ, UK
| | - J Vora
- From the Department of Endocrinology, Royal Liverpool University Hospital, Liverpool L7 8XP, UK
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Ilhan M, Tiryakioglu NO, Karaman O, Coskunpinar E, Yildiz RS, Turgut S, Tiryakioglu D, Toprak H, Tasan E. A novel AVP gene mutation in a Turkish family with neurohypophyseal diabetes insipidus. J Endocrinol Invest 2016. [PMID: 26208472 DOI: 10.1007/s40618-015-0357-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE Familial neurohypophyseal diabetes insipidus (FNDI) is a rare, autosomal dominant, inherited disorder which is characterized by severe polydipsia and polyuria generally presenting in early childhood. In the present study, we aimed to analyze the AVP gene in a Turkish family with FNDI. METHODS Four patients with neurohypophyseal diabetes insipidus and ten healthy members of the family were studied. Diabetes insipidus was diagnosed by the water deprivation test in affected family members. Mutation analysis was performed by sequencing the whole coding region of AVP-NPII gene using DNA isolated from peripheral blood samples. RESULTS Urine osmolality was low (<300 mOsm/kg) during water deprivation test, and an increase more than 50 % in urine osmolality and recovery of the symptoms were observed by the administration of desmopressin in all patients. Plasma copeptin levels were lower than expected according to plasma osmolality. Pituitary MRI revealed partial empty sella with a bright spot in index patient and a normal neurohypophysis in the other affected subjects. Genetic screening revealed a novel, heterozygous mutation designated as c.-3A>C in all patients. CONCLUSION c.-3A>C mutation in 5'UTR of AVP gene in this family might lead to the truncation of signal peptide, aggregation of AVP in the cytoplasm instead of targeting in the endoplasmic reticulum, thereby could disrupt AVP secretion without causing neuronal cytotoxicity, which might explain the presence of bright spot. The predicted effect of this mutation should be investigated by further in vitro molecular studies.
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Affiliation(s)
- M Ilhan
- Department of Endocrinology and Metabolism, Bezmialem University, Vatan Caddesi, 34093, Istanbul, Turkey.
| | - N O Tiryakioglu
- Department of Molecular Biology and Genetics, Halic University, Istanbul, Turkey
| | - O Karaman
- Department of Endocrinology and Metabolism, Bezmialem University, Vatan Caddesi, 34093, Istanbul, Turkey
| | - E Coskunpinar
- Division of Medical Genetics, Department of Internal Medicine, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - R S Yildiz
- Department of Internal Medicine, Bezmialem University, Vatan Caddesi, 34093, Istanbul, Turkey
| | - S Turgut
- Department of Internal Medicine, Bezmialem University, Vatan Caddesi, 34093, Istanbul, Turkey
| | - D Tiryakioglu
- Department of Basic Oncology, Oncology Institute, Istanbul University, Istanbul, Turkey
| | - H Toprak
- Department of Radiology, Bezmialem University, Vatan Caddesi, 34093, Istanbul, Turkey
| | - E Tasan
- Department of Endocrinology and Metabolism, Bezmialem University, Vatan Caddesi, 34093, Istanbul, Turkey
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Djermane A, Elmaleh M, Simon D, Poidvin A, Carel JC, Léger J. Central Diabetes Insipidus in Infancy With or Without Hypothalamic Adipsic Hypernatremia Syndrome: Early Identification and Outcome. J Clin Endocrinol Metab 2016; 101:635-43. [PMID: 26588450 DOI: 10.1210/jc.2015-3108] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
CONTEXT Neonatal central diabetes insipidus (CDI) with or without adipsia is a very rare complication of various complex hypothalamic disorders. It is associated with greater morbidity and a high risk of developing both hypernatremia and hyponatremia, due to the condition itself or secondary to treatment with vasopressin analogs or fluid administration. Its outcomes have yet to be evaluated. OBJECTIVE To investigate the clinical outcomes of patients with neonatal-onset CDI or adipsic CDI with hypernatremia. DESIGN, SETTING, AND PARTICIPANTS All patients diagnosed with neonatal CDI in a university hospital-based observational study and followed between 2005 and 2015 were included and analyzed retrospectively. MAIN OUTCOME MEASURES The various causes of CDI were grouped. Clinical outcome and comorbidities were analyzed. RESULTS Ten of the 12 patients had an underlying condition with brain malformations: optic nerve hypoplasia (n = 3), septo-optic dysplasia (n = 2), semilobar holoprosencephaly (n = 1), ectopic neurohypophysis (n = 3), and unilateral absence of the internal carotid artery (n = 1). The other two were idiopathic cases. During the median follow-up period of 7.8 (4.9-16.8) years, all but one patient displayed anterior pituitary deficiency. Transient CDI was found in three (25%) patients for whom a posterior pituitary hyperintense signal was observed with (n = 2) and without (n = 1) structural hypothalamic pituitary abnormalities, and with no other underlying cerebral malformations. Patients with permanent CDI with persistent adipsia (n = 4) and without adipsia (n = 5) required adequate fluid intake and various doses of desamino-D-arginine-8-vasopressin. Those with adipsia were more likely to develop hypernatremia (45 vs 33%), hyponatremia (16 vs 4%) (P < .0001), and severe neurodevelopmental delay (P < .05) than those without adipsia. Comorbidities were common. The underlying cause remains unknown at the age of 23 years for one patient with CDI and normal thirst. CONCLUSION Neonatal CDI may be transient or permanent. These vulnerable patients have high rates of comorbidity and require careful monitoring.
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Affiliation(s)
- Adel Djermane
- Assistance Publique-Hôpitaux de Paris (A.D., D.S., A.P., J.-C.C., J.L.), Hôpital Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, F-75019 Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Radiology Department (M.E.), Université Paris Diderot (A.P., J.-C.C., J.L.), Sorbonne Paris Cité, F-75019 Paris, France; and Inserm, Unité 1141 (J.-C.C., J.L.), DHU Protect, F-75019 Paris, France
| | - Monique Elmaleh
- Assistance Publique-Hôpitaux de Paris (A.D., D.S., A.P., J.-C.C., J.L.), Hôpital Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, F-75019 Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Radiology Department (M.E.), Université Paris Diderot (A.P., J.-C.C., J.L.), Sorbonne Paris Cité, F-75019 Paris, France; and Inserm, Unité 1141 (J.-C.C., J.L.), DHU Protect, F-75019 Paris, France
| | - Dominique Simon
- Assistance Publique-Hôpitaux de Paris (A.D., D.S., A.P., J.-C.C., J.L.), Hôpital Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, F-75019 Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Radiology Department (M.E.), Université Paris Diderot (A.P., J.-C.C., J.L.), Sorbonne Paris Cité, F-75019 Paris, France; and Inserm, Unité 1141 (J.-C.C., J.L.), DHU Protect, F-75019 Paris, France
| | - Amélie Poidvin
- Assistance Publique-Hôpitaux de Paris (A.D., D.S., A.P., J.-C.C., J.L.), Hôpital Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, F-75019 Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Radiology Department (M.E.), Université Paris Diderot (A.P., J.-C.C., J.L.), Sorbonne Paris Cité, F-75019 Paris, France; and Inserm, Unité 1141 (J.-C.C., J.L.), DHU Protect, F-75019 Paris, France
| | - Jean-Claude Carel
- Assistance Publique-Hôpitaux de Paris (A.D., D.S., A.P., J.-C.C., J.L.), Hôpital Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, F-75019 Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Radiology Department (M.E.), Université Paris Diderot (A.P., J.-C.C., J.L.), Sorbonne Paris Cité, F-75019 Paris, France; and Inserm, Unité 1141 (J.-C.C., J.L.), DHU Protect, F-75019 Paris, France
| | - Juliane Léger
- Assistance Publique-Hôpitaux de Paris (A.D., D.S., A.P., J.-C.C., J.L.), Hôpital Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, F-75019 Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Radiology Department (M.E.), Université Paris Diderot (A.P., J.-C.C., J.L.), Sorbonne Paris Cité, F-75019 Paris, France; and Inserm, Unité 1141 (J.-C.C., J.L.), DHU Protect, F-75019 Paris, France
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Turkkahraman D, Saglar E, Karaduman T, Mergen H. AVP-NPII gene mutations and clinical characteristics of the patients with autosomal dominant familial central diabetes insipidus. Pituitary 2015; 18:898-904. [PMID: 26134705 DOI: 10.1007/s11102-015-0668-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Familial central diabetes insipidus (DI), usually an autosomal dominant disorder, is caused by mutations in arginine vasopressin-neurophysin II (AVP-NPII) gene that leads to aberrant preprohormone processing and gradual destruction of AVP-secreting cells. OBJECTIVE To determine clinical and molecular characteristics of patients with familial central DI from two different Turkish families. MATERIALS AND METHODS The diagnosis of central DI was established by 24-h urine collection, water deprivation test, and desmopressin challenge. To confirm the diagnosis of familial central DI, the entire coding region of AVP-NPII gene was amplified and sequenced. A total of eight affected patients and three unaffected healthy relatives from two families were studied. RESULTS Genetic analysis revealed a previously reported heterozygous mutation (p.C98X) in family A, and a heterozygous novel mutation (p.G45C) in family B, both detected in exon 2 of AVP-NPII gene. When we compared the clinical characteristics of the two families, it was noticed that as the age of onset of symptoms in family A ranges between 4 and 7 years, it was <1 year in family B. Additionally, pituitary bright spot was present in the affected siblings, but absent in their affected parents. CONCLUSION Familial central DI is a progressive disease, and age of onset of symptoms can differ depending on the mutation. Bright spot on pituitary MRI might be present at onset, but become invisible over time. Genetic testing and appropriate counseling should be given in familial cases of central DI to ensure adequate treatment, and to avoid chronic water deprivation that might result in growth retardation in childhood.
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Affiliation(s)
- Doga Turkkahraman
- Department of Pediatric Endocrinology, Antalya Education and Research Hospital, Antalya, Turkey.
| | - Emel Saglar
- Department of Biology, Faculty of Science, Hacettepe University, Beytepe, Ankara, Turkey
| | - Tugce Karaduman
- Department of Biology, Faculty of Science, Hacettepe University, Beytepe, Ankara, Turkey
| | - Hatice Mergen
- Department of Biology, Faculty of Science, Hacettepe University, Beytepe, Ankara, Turkey
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Werny D, Elfers C, Perez FA, Pihoker C, Roth CL. Pediatric Central Diabetes Insipidus: Brain Malformations Are Common and Few Patients Have Idiopathic Disease. J Clin Endocrinol Metab 2015; 100:3074-80. [PMID: 26030323 DOI: 10.1210/jc.2015-1287] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
CONTEXT Pediatric cohorts of central diabetes insipidus (CDI) have shown varying prevalences for the different causes of CDI, including idiopathic. OBJECTIVE The objective of the study was to determine the causes of CDI at a pediatric tertiary care center and to characterize their clinical outcomes. DESIGN AND SETTING All patients with CDI at Seattle Children's Hospital were identified and retrospectively analyzed. PATIENTS From 2000 to 2013, 147 patients with CDI were encountered (mean age 7 y at diagnosis, mean follow-up 6.2 y). OUTCOME MEASURES The different causes of CDI were grouped, and age of diagnosis, anterior pituitary hormone deficiencies (APHDs), and presence of the posterior pituitary bright spot (PPBS) were analyzed. Patients with idiopathic CDI had infundibular thickening measured using a systematic method. RESULTS Brain malformations caused 24% of CDI cases, and 12.2% were idiopathic. Four of 22 patients with initially idiopathic CDI were diagnosed with an underlying condition, none occurring later than 2.5 years from diagnosis. APHDs were as common in the brain malformation group as they were in the tumor/infiltrative group (72% vs 85%; P = .09). The PPBS was present in at least 13% of patients and in 19% of those with brain malformations. Patients with idiopathic CDI and stalk thickening on the initial magnetic resonance imaging were more likely to have an underlying diagnosis (40% vs 0%; P = .03). CONCLUSIONS Brain malformations were a more common cause of pediatric CDI than previously reported. These patients have a high rate of APHDs, and many have persistence of the PPBS. Idiopathic CDI is an uncommon diagnosis, and none of our patients were diagnosed with Langerhans cell histiocytosis or germinoma for more than 3 years from CDI diagnosis. Providers can consider less frequent magnetic resonance imaging after this time point. A systematic method of infundibular measurement on the initial magnetic resonance imaging may predict an underlying germinoma or Langerhans cell histiocytosis.
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Affiliation(s)
- David Werny
- Division of Endocrinology and Diabetes (D.W., C.P., C.L.R.), Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington 98105; Center for Integrative Brain Research (C.E., C.L.R.), Seattle Children's Hospital, Seattle, Washington 98101; Department of Pediatric Endocrinology, Seattle Children's Hospital and Research Institute, and Department of Radiology (F.A.P.), Seattle Children's Hospital, University of Washington, Seattle, Washington 98105
| | - Clinton Elfers
- Division of Endocrinology and Diabetes (D.W., C.P., C.L.R.), Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington 98105; Center for Integrative Brain Research (C.E., C.L.R.), Seattle Children's Hospital, Seattle, Washington 98101; Department of Pediatric Endocrinology, Seattle Children's Hospital and Research Institute, and Department of Radiology (F.A.P.), Seattle Children's Hospital, University of Washington, Seattle, Washington 98105
| | - Francisco A Perez
- Division of Endocrinology and Diabetes (D.W., C.P., C.L.R.), Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington 98105; Center for Integrative Brain Research (C.E., C.L.R.), Seattle Children's Hospital, Seattle, Washington 98101; Department of Pediatric Endocrinology, Seattle Children's Hospital and Research Institute, and Department of Radiology (F.A.P.), Seattle Children's Hospital, University of Washington, Seattle, Washington 98105
| | - Catherine Pihoker
- Division of Endocrinology and Diabetes (D.W., C.P., C.L.R.), Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington 98105; Center for Integrative Brain Research (C.E., C.L.R.), Seattle Children's Hospital, Seattle, Washington 98101; Department of Pediatric Endocrinology, Seattle Children's Hospital and Research Institute, and Department of Radiology (F.A.P.), Seattle Children's Hospital, University of Washington, Seattle, Washington 98105
| | - Christian L Roth
- Division of Endocrinology and Diabetes (D.W., C.P., C.L.R.), Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington 98105; Center for Integrative Brain Research (C.E., C.L.R.), Seattle Children's Hospital, Seattle, Washington 98101; Department of Pediatric Endocrinology, Seattle Children's Hospital and Research Institute, and Department of Radiology (F.A.P.), Seattle Children's Hospital, University of Washington, Seattle, Washington 98105
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50
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Iwama S, Sugimura Y, Kiyota A, Kato T, Enomoto A, Suzuki H, Iwata N, Takeuchi S, Nakashima K, Takagi H, Izumida H, Ochiai H, Fujisawa H, Suga H, Arima H, Shimoyama Y, Takahashi M, Nishioka H, Ishikawa SE, Shimatsu A, Caturegli P, Oiso Y. Rabphilin-3A as a Targeted Autoantigen in Lymphocytic Infundibulo-neurohypophysitis. J Clin Endocrinol Metab 2015; 100:E946-54. [PMID: 25919460 PMCID: PMC5393526 DOI: 10.1210/jc.2014-4209] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 04/22/2015] [Indexed: 11/19/2022]
Abstract
CONTEXT Central diabetes insipidus (CDI) can be caused by several diseases, but in about half of the patients the etiological diagnosis remains unknown. Lymphocytic infundibulo-neurohypophysitis (LINH) is an increasingly recognized entity among cases of idiopathic CDI; however, the differential diagnosis from other pituitary diseases including tumors can be difficult because of similar clinical and radiological manifestations. The definite diagnosis of LINH requires invasive pituitary biopsy. OBJECTIVE The study was designed to identify the autoantigen(s) in LINH and thus develop a diagnostic test based on serum autoantibodies. DESIGN Rat posterior pituitary lysate was immunoprecipitated with IgGs purified from the sera of patients with LINH or control subjects. The immunoprecipitates were subjected to liquid chromatography-tandem mass spectrometry to screen for pituitary autoantigens of LINH. Subsequently, we made recombinant proteins of candidate autoantigens and analyzed autoantibodies in serum by Western blotting. RESULTS Rabphilin-3A proved to be the most diagnostically useful autoantigen. Anti-rabphilin-3A antibodies were detected in 22 of the 29 (76%) patients (including 4 of the 4 biopsy-proven samples) with LINH and 2 of 18 (11.1%) patients with biopsy-proven lymphocytic adeno-hypophysitis. In contrast, these antibodies were absent in patients with biopsy-proven sellar/suprasellar masses without lymphocytic hypophysitis (n = 34), including 18 patients with CDI. Rabphilin-3A was expressed in posterior pituitary and hypothalamic vasopressin neurons but not anterior pituitary. CONCLUSIONS These results suggest that rabphilin-3A is a major autoantigen in LINH. Autoantibodies to rabphilin-3A may serve as a biomarker for the diagnosis of LINH and be useful for the differential diagnosis in patients with CDI.
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MESH Headings
- Adaptor Proteins, Signal Transducing/immunology
- Adaptor Proteins, Signal Transducing/metabolism
- Adult
- Animals
- Autoantibodies/blood
- Autoantigens/immunology
- Autoimmune Diseases/blood
- Autoimmune Diseases/immunology
- Autoimmune Diseases/metabolism
- Diabetes Insipidus, Neurogenic/blood
- Diabetes Insipidus, Neurogenic/diagnosis
- Diabetes Insipidus, Neurogenic/immunology
- Diabetes Insipidus, Neurogenic/metabolism
- Diagnosis, Differential
- Female
- HEK293 Cells
- Humans
- Lymphocytes/immunology
- Male
- Nerve Tissue Proteins/immunology
- Nerve Tissue Proteins/metabolism
- Pituitary Gland, Posterior/immunology
- Pituitary Gland, Posterior/metabolism
- Rats
- Rats, Sprague-Dawley
- Vesicular Transport Proteins/immunology
- Vesicular Transport Proteins/metabolism
- Young Adult
- Rabphilin-3A
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Affiliation(s)
- Shintaro Iwama
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Yoshihisa Sugimura
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Atsushi Kiyota
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Takuya Kato
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Atsushi Enomoto
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Haruyuki Suzuki
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Naoko Iwata
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Seiji Takeuchi
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Kohtaro Nakashima
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Hiroshi Takagi
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Hisakazu Izumida
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Hiroshi Ochiai
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Haruki Fujisawa
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Hidetaka Suga
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Hiroshi Arima
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Yoshie Shimoyama
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Masahide Takahashi
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Hiroshi Nishioka
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - San-e Ishikawa
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Akira Shimatsu
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Patrizio Caturegli
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
| | - Yutaka Oiso
- Department of Endocrinology and Diabetes (S.Iw., Y.Su., A.K., H.S., N.I., S.T., K.N., H.T., H.I., H.O., H.F., H.S., H.A., Y.O.) and Department of Pathology (T.K., A.E., M.T.), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan; Research Center of Health, Physical Fitness and Sports (S.Iw.), Nagoya University, Nagoya 464-8601, Japan; Department of Pathology and Clinical Laboratory (Y.Sh.), Nagoya University Hospital, Nagoya 466-8560, Japan; Department of Hypothalamic and Pituitary Surgery (H.N.), Toranomon Hospital, Tokyo 105-0001, Japan; Department of Medicine (S.Is.), Jichi Medical University Saitama Medical Center, Saitama, 330-8503, Japan; Clinical Research Institute (A.S.), National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; Department of Pathology (P.C.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21205; Feinstone Department of Molecular Microbiology and Immunology (P.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Japan Hypophysitis Research Group (S.Iw., Y.Su., H.N., S.Is., A.S., Y.O.), Nagoya 466-8550, Japan
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