Persistent hypernatremia secondary to adipsic central diabetes insipidus in a patient with herpes-induced meningoencephalitis and COVID-19 infection: a case report

Central diabetes insipidus (CDI) typically manifests as a polyuria-polydipsia syndrome, in which normonatremia is generally maintained through the polydipsia. A 53-year-old woman presented with diabetic ketosis and hyperosmolar hyperglycemic syndrome. Her medical history included herpes meningoencephalitis, which was associated with confusion and amnesia. On physical examination, she was apyretic, confused, and had signs of extracellular dehydration. Her capillary glucose concentration was high and her urine was positive for ketones. Laboratory investigations revealed severe hyperglycemia, hypernatremia (plasma hyperosmolarity of 393.6 mOsm/L), and mild acute renal failure. In addition, she had a paucisymptomatic COVID-19 infection. Intravenous rehydration with isotonic saline solution and insulin therapy were effective at controlling the ketosis and ameliorating the hyperglycemia, but failed to normalize the hypernatremia and hyperosmolarity. She was not thirsty and had a urine output of 1 L/day, with urinary hypotonicity. Desmopressin administration reduced the hypernatremia and hyperosmolarity to within their normal ranges, and the patient's urinary osmolarity increased to 743 mOsm/L. Therefore, adipsic CDI was diagnosed. Endocrine investigations revealed isolated central hypothyroidism. The results of pituitary magnetic resonance imaging were normal. Thus, patients with impaired thirst may have an atypical presentation of CDI. In addition, the diagnosis of adipsic CDI is particularly challenging.

Hypothalamic and Pituitary Dysfunction After Extensive Brain Surgery: There Is Thirst for More Knowledge

Craniopharyngiomas are tumors originating from the infundibular stalk, extending to the parasellar and suprasellar region, thereby conferring multiple risks of this region. In particular, hypothalamic and pituitary damage related to its natural history as well as treatment effects of craniopharyngiomas substantially affect life expectancy and quality of life. Here, we describe an adult patient presenting with polyuria, memory, and visual field impairment secondary to concurrent craniopharyngioma and intraventricular glioma. He was treated with surgical resection with postoperative course notable for hypothalamic-pituitary dysfunction, including central hypothyroidism, central adrenal insufficiency, arginine vasopressin deficiency (AVP-D, formerly diabetes insipidus) with loss of sense of thirst, and hypothalamic hypothermia. The adipsia, combined with memory dysfunction, challenged the management of constant fluctuations in his sodium (129-168 mEq/L), with ultimate treatment through vasopressin repletion, fixed fluid intake, strict urine output monitoring, and close counseling of the patient and his caregiver. This case exemplifies the complexity of the endocrine care of patients with craniopharyngiomas and highlights the need for step-wise algorithms in the treatment of hypothalamic deficiencies such as adipsia.

Type D Adipsia with Severe Hypernatremia: A Unique Presentation of an Extensive Intracranial Germinoma

Intracranial germ cell tumors are uncommon brain tumors; germinoma is the most common tumor in children and young adults, and the most common regions affected are pineal gland and suprasellar region. Germinomas of the suprasellar region are accompanied by endocrine alterations, with adipsia being a rare presentation. Here, we present the case of a patient with an extensive intracranial germinoma whose initial presentation was adipsia, without any other endocrinological alteration, with development of severe hypernatremia and unusual manifestations derived from it, such as deep vein thrombosis, myopathy with rhabdomyolysis, and neurological axonal damage.

Diagnosis and Management of Central Diabetes Insipidus in Adults

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.

Recurrent Adipsic Hypernatremia in a Fully Independent Non-psychiatric Patient With Multiple Congenital Anomalies: A Case Report

Osmoregulation is a fundamental process of homeostasis that maintains metabolic and biochemical reactions, thermoregulation, and fluid-electrolytes balance. Fluid-electrolytes imbalance leads to various clinical manifestations ranging from mild weakness to severe neurological dysfunction. Adipsic hypernatremia is an exceedingly rare life-threatening condition characterized by defective osmoregulatory mechanisms. It is more often reported in patients with severe untreated psychiatric disorders for unknown etiologies, but it may result from congenital or acquired hypothalamic lesions in the form of stroke, neoplastic infiltration, trauma, or infection. Herein we report an unusual case of isolated hypernatremia in a fully independent non-psychiatric 27-year-old diabetic male with spina bifida, repaired cleft palate, and mild caudal regression syndrome.

[Central diabetes insipidus after resection of sellar-suprasellar tumors: prevalence and predictors of manifestation]

Central diabetes insipidus is a neuroendocrine disorder caused by disturbances in antidiuretic hormone release. The last one is responsible for fluid and electrolyte balance regulation. The most common cause of diabetes insipidus is resection of sellar-suprasellar tumors followed by damage to hypothalamic nuclei responsible for antidiuretic hormone release, disruption of antidiuretic hormone transportation from hypothalamus or its release by neurohypophysis. According to various data, postoperative diabetes insipidus occurs in 13-30% of cases. The highest risk of diabetes insipidus is observed after resection of craniopharyngioma, Rathke's cleft cyst and ACTH-releasing pituitary microadenoma. This review is devoted to prevalence and predictors of diabetes insipidus after resection of sellar-suprasellar tumors.

No evidence of sickness behavior in immune-challenged field crickets

Sickness behavior is a taxonomically widespread coordinated set of behavioral changes that increases shelter-seeking while reducing levels of general activity, as well as food (anorexia) and water (adipsia) consumption, when fighting infection by pathogens and disease. The leading hypothesis explaining such sickness-related shifts in behavior is the energy conservation hypothesis. This hypothesis argues that sick (i.e., immune-challenged) animals reduce energetic expenditure in order have more energy to fuel an immune response, which in some vertebrates, also includes producing an energetically expensive physiological fever. We experimentally tested the hypothesis that an immune challenge with lipopolysaccharide (LPS) will cause Gryllus firmus field crickets to reduce their activity, increase shelter use and avoid foods that interfere with an immune response (i.e., fat) while preferring a diet that fuels an immune response (i.e., protein). We found little evidence of sickness behavior in Gryllus firmus as immune-challenged individuals did not reduce their activity or increase their shelter-seeking. Neither did we observe changes in feeding or drinking behavior nor a preference for protein or avoidance of lipids. Males tended to use shelters less than females but no other behaviors differed between the sexes. The lack of sickness behavior in our study might reflect the fact that invertebrates do not possess energetically expensive physiological fever as part of their immune response. Therefore, there is little reason to conserve energy via reduced activity or increased shelter use when immune-challenged.

Daily Sodium Monitoring and Fluid Intake Protocol: Preventing Recurrent Hospitalization in Adipsic Diabetes Insipidus

Management of diabetes insipidus (DI) is usually facilitated by an intact thirst mechanism prompting water ingestion in times of rising osmolality. Maintenance of eunatremia can be quite difficult in patients with DI and adipsia because of the absence of this homeostatic mechanism. Few published protocols for management of these complex cases exist. We report a case of a 16-year-old girl who had a diagnosis of craniopharyngioma with preoperative hypopituitarism and central DI. She underwent transsphenoidal resection in 2013 and additionally developed postoperative cognitive impairment and hypothalamic dysfunction, including adipsia. She subsequently experienced widely dysregulated sodium levels, necessitating inpatient care ∼30% of days in 2014 and 2015. We created a protocol for this patient that uses a fixed daily dose of subcutaneous DDAVP combined with daily modulation of fluid intake based on daily serum sodium measurement. The protocol provides guidance for the day's fluid intake based on both the current sodium result and the rate of change from the previous day. Since the adoption of the protocol in June 2016, the patient has had a dramatic reduction in hospitalizations. Use of a protocol for providing recommendations for fluid intake based on the sodium level and rate of change may help to maintain normal sodium levels in such patients, decreasing hospitalization and improving quality of life.

Adipsic Diabetes Insipidus-The Challenging Combination of Polyuria and Adipsia: A Case Report and Review of Literature

Adipsic Diabetes Insipidus is a rare hypothalamic disorder characterized by a loss of thirst in response to hypernatraemia accompanied by diabetes insipidus. These occur secondary to a congregation of defects in the homeostatic mechanisms of water balance. A 27-year old Chinese female presented with Adipsic Diabetes Insipidus after cerebral arteriovenous malformation (AVM) surgery. Initial diagnosis and management was extremely challenging. Long term management required a careful interplay between low dose vasopressin analog treatment and fluids. Detailed charts of medication and sodium balance are described in the case presentation. We performed a literature search of similarly reported cases and describe the possible pathogenesis, etiology, clinical presentation, acute and chronic management, and prognosis.

Presence of Probst Bundles Indicate White Matter Remodeling in a Dog With Corpus Callosum Hypoplasia and Dysplasia

Corpus callosum abnormalities (CCA) rarely occur in dogs and are related to hypo/adypsic hypernatremia and seizures. Hypoplasia and dysplasia of the corpus callosum (CC) with concomitant lobar holoprosencephaly is the most common variant. It is currently uncertain using conventional MRI if canine CCA reflects the failure of commissural fibers to develop or the failure of the commissural fibers to cross hemispheres. Diffusion tensor imaging was performed in a 4-year-old Staffordshire mix breed dog with CCA and an age-matched healthy Beagle. In comparison to the control dog, CC tractography of the affected dog depicted only axonal tracts corresponding to the temporal CC fibers. The cingulum bundles appeared supernumerary with unorganized architecture, extending into the ipsilateral cerebral cortex, and therefore strongly suggested homology to Probst bundles reported in humans with CCA. The presence of Probst bundles in canine CCA could represent compensatory neuroplasticity-mediated networking and may contribute the fair prognosis reported in affected dogs.

Case Report: Severe hypernatremia from psychogenic adipsia

Hypernatremia is a common emergency room presentation and carries high mortality. We describe a case of a 56-year-old male patient with who presents with refusal to drink water for several weeks leading to the admission. He was diagnosed with psychogenic adipsia and was treated successfully with fluids, mirtazapine and clonazepam.

Management of diabetes insipidus and adipsia in the child

Central diabetes insipidus (CDI) is a complex and heterogeneous clinical syndrome affecting the hypothalamic-neurohypophyseal network and water balance. A recent national surveillance in Denmark showed a prevalence rate of twenty-three CDI patients per 100,000 inhabitants in five years. The differential diagnosis between several presenting conditions with polyuria and polydipsia is puzzling, and the etiological diagnosis of CDI remains a challenge before the identification of an underlying cause. For clinical practice, a timely diagnosis for initiating specific treatment in order to avoid central nervous system damage, additional pituitary defects and the risk of dissemination of germ cell tumor is advisable. Proper etiological diagnosis can be achieved via a series of steps that start with careful clinical observation of several signs and endocrine symptoms and then progress to more sophisticated imaging tools. This review summarizes the best practice and approach for the diagnosis and treatment of patients with CDI.