Cerebral Malaria: An Unusual Cause of Central Diabetes Insipidus

Central diabetes insipidus is an uncommon feature of malaria. A previously healthy 72-year-old man presented with fever, rigors, and altered mental status after a recent trip to Liberia, a country known for endemic falciparum malaria. Investigations confirmed plasmodium falciparum parasitemia. Within one week after admission, the serum sodium rose to 166 mEq/L and the urine output increased to 7 liters/day. Other labs were notable for a high serum osmolality, low urine osmolality, and low urine specific gravity. The hypernatremia did not respond to hypotonic fluids. Diabetes insipidus was suspected and parenteral desmopressin was started with a prompt decrease in urinary output and improvement in mental status. Additional testing showed normal anterior pituitary hormones. The desmopressin was eventually tapered off with complete resolution of symptoms. Central diabetes insipidus occurred likely as a result of obstruction of the neurohypophyseal microvasculature. Other endocrinopathies that have been reported with malaria include hyponatremia, adrenal insufficiency, hypothyroidism, hypocalcemia, hypophosphatemia, hyper-, and hypoglycemia, but none manifested in our patient. Though diabetes insipidus is a rare complication of malaria, clinicians need to be aware of this manifestation, as failure to do so may lead to fatality particularly if the patient is dehydrated.

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MON-LB65 Lithium: The Culprit of Multiple Endocrinopathies

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.2227 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Alice Yau ◽

Gul Bahtiyar ◽

Giovanna Rodriguez ◽

Jose R Martinez Escudero

Keyword(s):

Bipolar Disorder ◽

Diabetes Insipidus ◽

Mental Status ◽

Nephrogenic Diabetes Insipidus ◽

Kidney Injury ◽

Urine Osmolality ◽

Altered Mental Status ◽

Clinical Findings ◽

Volume Depletion ◽

Collecting Tubules

Abstract Background: Lithium, commonly used to treat various psychiatric disorders such as bipolar disorder, can cause acute toxicity that presents with nausea, vomiting and diarrhea. Lithium can also cause life-threatening endocrine abnormalities, including hypercalcemia, hypernatremia, and both hypo- and hyperthyroidism. Clinical Case: A 61-year old female with hypothyroidism, bipolar disorder, hyperparathyroidism with two-gland parathyroidectomy on lithium for over 30 years presented with altered mental status. Initial labs revealed elevated creatinine 1.92 mg/dL (0.8-2.00mg/dL) compared to baseline 0.82 mg/dL, sodium 154 mg/dL (135-147 mg/dL), Corrected calcium 11.7 mg/dL (8.5-10.5 mg/dL), PTH 96 pg/mL (15-65 pg/mL), and high lithium levels 1.45 mmol/L (0.60-1.20 mmol/L). Further studies showed hypotonic polyuria with no increase in urine osmolality after desmopressin, consistent with nephrogenic diabetes insipidus. Lithium was held and she was treated with aggressive intravenous hydration with dextrose 5% water. Hypercalcemia is thought to result from increased secretion of PTH due to an increased set point at which calcium suppresses PTH release; this often resolves once lithium is stopped. Lithium can also unmask previously unrecognized mild hyperparathyroidism, and/or raise serum PTH concentrations independent of calcium levels.1 The drug interferes with the kidneys’ ability to concentrate urine in the collecting tubules by desensitizing response to antidiuretic hormone, causing diabetes insipidus. The resulting volume depletion from excessive urinary water loss in turn lead to acute kidney injury and hypernatremia.2 Hypothyroidism results from lithium-inhibited synthesis and release of thyroid hormones and decreases iodine trapping. Conclusion: Although these are infrequent complications of lithium use, they remain pertinent clinical findings to consider due to their morbidity. In this case, our patient may have avoided multiple chronic electrolyte abnormalities leading to altered mental status if lithium toxicity had been recognized earlier. References:1. García-Maldonado, Gerardo, and Rubén de Jesús Castro-García. “Endocrinological Disorders Related To The Medical Use Of Lithium. A Narrative Review”. Revista Colombiana De Psiquiatría (English Ed.), vol 48, no. 1, 2019, pp. 35-43. Elsevier BV, doi:10.1016/j.rcpeng.2018.12.005. 2. Tasci, E. “Lithium-Induced Nephrogenic Diabetes Insipidus Responsive To Desmopressin”. Acta Endocrinologica (Bucharest), vol 15, no. 2, 2019, pp. 270-271. ACTA Endocrinologica Foundation, doi:10.4183/aeb.2019.270.

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One too many diabetes: the combination of hyperglycaemic hyperosmolar state and central diabetes insipidus

Endocrinology Diabetes and Metabolism Case Reports ◽

10.1530/edm-18-0029 ◽

2018 ◽

Vol 2018 ◽

Cited By ~ 1

Author(s):

Snezana Burmazovic ◽

Christoph Henzen ◽

Lukas Brander ◽

Luca Cioccari

Keyword(s):

Diabetes Mellitus ◽

Glycaemic Control ◽

Specific Gravity ◽

Diabetes Insipidus ◽

Urine Osmolality ◽

Central Diabetes Insipidus ◽

Urine Specific Gravity ◽

List Type ◽

Poor Glycaemic Control ◽

History Of

Summary The combination of hyperosmolar hyperglycaemic state and central diabetes insipidus is unusual and poses unique diagnostic and therapeutic challenges for clinicians. In a patient with diabetes mellitus presenting with polyuria and polydipsia, poor glycaemic control is usually the first aetiology that is considered, and achieving glycaemic control remains the first course of action. However, severe hypernatraemia, hyperglycaemia and discordance between urine-specific gravity and urine osmolality suggest concurrent symptomatic diabetes insipidus. We report a rare case of concurrent manifestation of hyperosmolar hyperglycaemic state and central diabetes insipidus in a patient with a history of craniopharyngioma. Learning points: In patients with diabetes mellitus presenting with polyuria and polydipsia, poor glycaemic control is usually the first aetiology to be considered. However, a history of craniopharyngioma, severe hypernatraemia, hyperglycaemia and discordance between urine-specific gravity and osmolality provide evidence of concurrent diabetes insipidus. Therefore, if a patient with diabetes mellitus presents with severe hypernatraemia, hyperglycaemia, a low or low normal urinary-specific gravity and worsening polyuria despite correction of hyperglycaemia, concurrent diabetes insipidus should be sought.

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Interesting and Rare Case of Central Diabetes Insipidus in a Patient With Acute Myeloid Leukemia

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.1201 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A589-A589

Author(s):

Chheki Sherpa ◽

Bishow Chandra Shrestha ◽

Swarup S Rijal ◽

Ilan Gabriely ◽

Deepika Nallala ◽

...

Keyword(s):

Acute Myeloid Leukemia ◽

Specific Gravity ◽

Diabetes Insipidus ◽

Myeloid Leukemia ◽

Urine Osmolality ◽

Central Diabetes Insipidus ◽

Urine Specific Gravity ◽

Bright Spot ◽

Monosomy 7 ◽

Acute Myeloid

Abstract Introduction: Central Diabetes Insipidus (CDI) is the lack of antidiuretic hormone (ADH) leading to impaired urinary concentration and manifests with extreme thirst and excessive urination. Patients unable to drink fluids are at risk of severe dehydration and hypernatremia. CDI can be a rare complication of acute myeloid leukemia (AML). The occurrence of AML with CDI is extremely rare with only few case reports published. This combination of AML with CDI has been reported to be associated with monosomy 7 and inversion (3) (q21q26) and portends an overall a very poor treatment response resulting in poor outcomes. Case Presentation: 66-year-old female with hypertension, polycythemia vera diagnosed in 2006 with transformation to AML in 2020. FISH studies revealed monosomy 7. Cytogenetic studies showed inv (3)(q21q26.2). Remission induction chemotherapy was initiated. Subsequently, neutropenic fever and sepsis secondary to Clostridium difficile colitis lead to hospitalization. Her sodium (Na) level gradually trended up and reached a peak of 157 mmol/l (range 136-145) and elevated serum osmolality at 311 mOsm/K with low urine osmolality 135 mOsm/K, low urine sodium at 13 and low urine specific gravity 1.006 concerning for CDI. She developed polyuria and received desmopressin (DDAVP) leading to improvements in urine osmolality to 267 mOsm/K, 30 minutes indicating CDI diagnosis. Her Na gradually normalized to 144 mmol/l, urine osmolality improved to 580 mOsm/K and urine specific gravity to 1.025. She is now on DDAVP 0.05 mg oral twice daily and her Na is in normal range. MRI pituitary did not show any evidence of metastatic lesion with intact pituitary bright spot. Her other pituitary hormonal workup was normal except for hypogonadotropic hypogonadism. Discussion: The pathophysiology of AML and CDI is unclear. Leukemic cells infiltration of the neurohypophysis; thrombosis of small vessels in hypothalamic nuclei and the posterior pituitary; alterations of the neutrophil migration placed on the chromosome 7 leading to glycoprotein gp 130 production, a cell surface marker on granulocytes are some of hypothesis suggested. CDI has a variable onset in the course of myeloid malignancies. MRI pituitary can be normal in most of the cases.

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Intracranial pathologies associated with central diabetes insipidus in infants

Journal of Pediatric Endocrinology and Metabolism ◽

10.1515/jpem-2017-0300 ◽

2018 ◽

Vol 31 (9) ◽

pp. 951-958 ◽

Cited By ~ 1

Author(s):

Nader Kasim ◽

Bindiya Bagga ◽

Alicia Diaz-Thomas

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Cerebral Infarction ◽

Diabetes Insipidus ◽

Intraventricular Hemorrhage ◽

Urine Osmolality ◽

High Serum ◽

Central Diabetes Insipidus ◽

Intracranial Injury ◽

Included Patient

Abstract Background Idiopathic central diabetes insipidus (CDI) has been associated with intracranial pathologies that do not involve the structural pituitary gland or hypothalamus. The objective was to study the association between non-structural hypothalamic/pituitary intracranial pathologies (NSHPIP) with CDI and to review etiologies that may be contributory to the development of CDI. Methods A retrospective query of our intra-institutional database from 2006 to 2015. Children admitted diagnosed with diabetes insipidus (DI) (ICD-9 253.5) between the ages of 0–1 year were included. Patient charts were reviewed to include those who have a documented diagnosis of CDI, hypernatremia (>145 mmol/L), high serum osmolality (>300 mOsm/kg), low urine osmolality (<300 mOsm/kg), and brain imaging reports. Diagnoses of nephrogenic DI were excluded. Results Twenty-three infant patients were diagnosed with CDI. Eleven subjects (48%) had NSHPIP. Of those, 18% had cerebral infarction, 27% had intracranial injury and hemorrhage due to traumatic brain injury, 18% had isolated intraventricular hemorrhage, and 27% had meningitis. Hospital prevalence for NSHPIP, age 0–1 year, ranged from 0.05% to 0.3%. Conclusions Rates of NSHPIP in those with CDI are higher than expected hospital rates (p<0.001), suggesting a possible association between CDI and NSHPIP.

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Efficacy and comparative analysis of consumer qualities of the Desmopressin intranasal drops in patients with central diabetes insipidus

Obesity and metabolism ◽

10.14341/omet2014331-36 ◽

2014 ◽

Vol 11 (3) ◽

pp. 31-36

Author(s):

Ekaterina Aleksamdrovna Pigarova ◽

Larisa Konstantinovna Dzeranova ◽

Lyudmila Yakovlevna Rozhinskaya

Keyword(s):

Comparative Analysis ◽

Diabetes Insipidus ◽

Dose Calculation ◽

Study Drug ◽

Storage Conditions ◽

Central Diabetes Insipidus ◽

Urine Specific Gravity ◽

Investigational Drug ◽

Calculation Algorithm ◽

Initiation Of Therapy

Objective: To evaluate the effectiveness and conduct a comparative analysis of consumer qualities of desmopressin intranasal drops 0.01% 5ml ("Biopharm", Georgia) in patients with central diabetes insipidus (CDI). Materials and Methods: The study included 9 patients (3 men and 6 women, mean age 44 ± 12 years) diagnosed with CDI. Patients for 7 days were switched to desmopressin intranasal drops 0.01% (JSC "Biopharm" Georgia) from there basal desmopressin preparations by means of recalculating daily dose by proposed formular: 10 mg (2 drops) of desmopressin intranasal drops = 0.2 mg of desmopressin tableted = 10 micrograms (one dose) of intranasal spray metered desmopressin = 120 mcg sublingual tablets of desmopressin. Safety biochemical parameters, efficiency to control of the main manifestations of CDI, increase in urine specific gravity, quality of life, basic consumer properties of different desmopressin preparation were evaluates at baseline and after treatment period. Results: Desmopressin nasal drops 0.01% showed to be an effective drug for the treatment of patients with CDI. Dose calculation algorithm daily was adequate in most patients. Hyponatremia was detected in 2 out of 9 patients during the study period but has been related to study drug alone in one case. The investigational drug was marked convenient to use by less than 25% of patients which may be associated with the pharmacological form of the drug as intranasal drops with special storage conditions (refrigerator). Conclusions: The drug desmopressin intranasal drops can be recommended as a second line (reserve) therapy in the treatment of patients CDI. Sodium levels should be checked during initiation of therapy.

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A Fatal Case of Primary Amoebic Meningoencephalitis (PAM) Complicated with Diabetes Insipidus (DI): A Case Report and Review of the Literature

Case Reports in Infectious Diseases ◽

10.1155/2020/4925819 ◽

2020 ◽

Vol 2020 ◽

pp. 1-3

Author(s):

Muhammad Zain Mushtaq ◽

Saad Bin Zafar Mahmood ◽

Adil Aziz

Keyword(s):

Diabetes Insipidus ◽

Rare Complication ◽

Fatal Case ◽

Urine Osmolality ◽

Developed Countries ◽

Polymorphonuclear Cells ◽

Naegleria Fowleri ◽

Primary Amoebic Meningoencephalitis ◽

Nægleria Fowleri ◽

Amoebic Meningoencephalitis

Naegleria fowleri is a highly infective free-living amoeba usually isolated from soil and fresh water and is primarily found to infect the central nervous system (CNS) resulting in primary amoebic meningoencephalitis (PAM). PAM as a cause of meningitis is often overlooked for other, more common causes of meningitis. Despite all the advances in antimicrobial therapy and supportive care systems, the mortality rate of this rare infection remains above 95% with the bulk of the cases being found in developed countries. We are presenting a case of a 44-year-old male with fever, worsening headache, and generalized weakness. Lumbar puncture showed a raised leucocyte count of 1100/µL with predominant polymorphonuclear cells, and wet mount prep for Naegleria fowleri was positive further confirmed with PCR. The patient was started Intravenous (IV) and intrathecal amphotericin-B, Per Oral (PO) miltefosine, IV rifampin, IV fluconazole, and IV dexamethasone. However, the patient started producing urine at 300–500 ml/hour. The patient’s sodium levels increased from 144 to 175 mmol/L in 12 hours with raised serum osmolality and decreased urine osmolality and urine sodium. The patient was started on PO desmopressin of 0.2 micrograms twice daily after which his urine output dropped to 60–80 ml/hour and sodium decreased from 175 to 162 and, later 155 mmol/L; however, the patient expired. PAM is a rare and extremely fatal illness, but with increasing incidence now being reported in developing countries as a result of better diagnostics. DI is a very rare complication reported in these patients leading to poor outcome. The complication of diabetes insipidus (DI) has not been extensively studied in patients having PAM. Only three cases have been reported with this complication. No mechanism has been mentioned in the literature behind the development of DI in these patients, and no study has mentioned laboratory details of DI as mentioned in this report.

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Central diabetes insipidus misdiagnosed as acute gastroenteritis in a pediatric patient

CJEM ◽

10.1017/s1481803500010642 ◽

2008 ◽

Vol 10 (05) ◽

pp. 488-492

Author(s):

Laleh Gharahbaghian ◽

Shahram Lotfipour ◽

Christopher E. McCoy ◽

Wirachin Hoonpongsimanont ◽

Mark Langdorf

Keyword(s):

Diabetes Insipidus ◽

Acute Gastroenteritis ◽

Clinical Status ◽

Vital Signs ◽

Fluid Challenge ◽

Pediatric Intensive Care ◽

Central Diabetes Insipidus ◽

Urine Specific Gravity ◽

Loss Of Function ◽

Severe Dehydration

ABSTRACT This case report describes an unusual presentation of nausea, vomiting and diarrhea, which was misdiagnosed as acute gastroenteritis in a 6-year-old girl. The patient later returned to the emergency department (ED) with severe dehydration from idiopathic central diabetes insipidus (DI). At her first visit, this previously healthy patient presented with mild dehydration, signs of acute gastroenteritis and normal urine output. Her brother had experienced similar symptoms a few days earlier. She tolerated an oral fluid challenge and was discharged from the ED with stable vital signs. Two days later, the patient returned with severe dehydration, resolving diarrhea and persistent vomiting. She was admitted to the pediatric intensive care unit. Magnetic resonance imaging illustrated an absent posterior pituitary enhancing signal, which demonstrated a loss of function in that region. There were no other abnormalities. The patient subsequently received desmopressin with improving clinical status and was discharged on the eighth hospital day. DI is a rare disease, but can be fatal if left undiagnosed. It should, therefore, be considered in the differential diagnosis of a dehydrated patient with an unexpectedly low urine specific gravity.

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Central Nervous System Metastases in Patients With Cervical Carcinoma

International Journal of Gynecological Cancer ◽

10.1097/igc.0000000000000827 ◽

2016 ◽

Vol 26 (9) ◽

pp. 1686-1689 ◽

Cited By ~ 4

Author(s):

Bernardo Cacho-Díaz ◽

Nydia A. Lorenzana-Mendoza ◽

Rosa M. Michel-Ortega ◽

Gervith Reyes-Soto ◽

Alejandro Monroy-Sosa ◽

...

Keyword(s):

Central Nervous System ◽

Nervous System ◽

Mental Status ◽

Lung Metastases ◽

Rare Complication ◽

Altered Mental Status ◽

Visual Disturbance ◽

Common Symptom ◽

Gynecology And Obstetrics ◽

Common Malignancy

IntroductionCervical cancer (CC) is the most common malignancy throughout developing countries, although considered rare, central nervous system metastasis (CNSm) does occur.ObjectiveThis study aimed to describe our experiences and compare them to other published cases.Materials and MethodsFrom May 2009 to August 2015, the files of all patients with CC treated at our referral center were reviewed.ResultsWe found 27 patients with CC and CNSm. Mean age at the time of CNS diagnosis was 50 ± 11 years, mean interval between initial CC and CNSm was 46 months; the most frequent initial International Federation of Gynecology and Obstetrics stage was IIB with 17 patients followed by IB in 4. Fifty-nine percent of patients had lung metastases at the time CNSm were diagnosed. Headache was the most common symptom, followed by weakness, altered mental status, and ataxia/cerebellar. Mean survival was 8.2 months after CNSm was discovered; 3 patients are still alive.ConclusionsThe present study describes the largest series of patients with CNSm from CC; this rare complication should be suspected in patients with CC who present with headache, ataxia, cranial nerve palsy, visual disturbance, altered mental status, focal weakness, or other neurological symptom, without other plausible explanation.

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Diabetes Insipidus and Concomitant Myocarditis: A Late Sequelae of COVID-19 Infection

Journal of Investigative Medicine High Impact Case Reports ◽

10.1177/2324709621999954 ◽

2021 ◽

Vol 9 ◽

pp. 232470962199995

Author(s):

Abu Baker Sheikh ◽

Nismat Javed ◽

Abdul Ahad Ehsan Sheikh ◽

Shubhra Upadhyay ◽

Rahul Shekhar

Keyword(s):

Diabetes Insipidus ◽

Young Male ◽

Urine Osmolality ◽

High Serum ◽

Test Results ◽

Global Pandemic ◽

Laboratory Test Results ◽

Late Sequela ◽

Endocrine Complications

Severe acute respiratory syndrome coronavirus 2 causes coronavirus disease 2019 (COVID-19), which has become a global pandemic. Apart from the mild features of the disease, long-term complications involve many systems including both endocrine and cardiovascular systems. Myocarditis, secondary to COVID-19, has become a well-known complication of the disease. However, endocrine complications are generally not common, particularly isolated pituitary abnormalities. There is one other report of diabetes insipidus developing as a late sequela of COVID-19. In this article, we report a case of a young male who presented with features of myocarditis but developed diabetes insipidus on day 7 of admission as a long-term complication after recovery from COVID-19 infection. His laboratory test results at the time of developing the complication revealed a high serum sodium level and low urine osmolality. The patient recovered on administration of desmopressin and was discharged after 16 days of hospitalization.

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Acute Transient Central Diabetes Insipidus: A Rare Case of DI Secondary to Vasopressin Withdrawal

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.1164 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A571-A571

Author(s):

Crystal Cobb ◽

Ibitoro Nnenna Osakwe

Keyword(s):

Diabetes Insipidus ◽

Serum Sodium ◽

Clinical Picture ◽

Urine Output ◽

Early Recognition ◽

Bowel Perforation ◽

Fluid Management ◽

Urine Volume ◽

Urine Osmolality ◽

Central Diabetes Insipidus

Abstract Introduction: Transient Central Diabetes Insipidus (tCDI) induced by vasopressin withdrawal is a rare condition which is possibly under recognized. It occurs in very sick, often critically ill patients and usually complicates an already complex clinical picture, so early recognition and treatment are critical to reduce morbidity. Case Description: A 47-y/o male with a PMH of Coffin Lowry syndrome, atrial fibrillation, and GERD presented with abdominal pain and flu like symptoms. His home medications were metoprolol, loratadine and colestipol. Work up revealed bowel perforation for which he was taken to the OR for repair. Intraoperatively he developed septic shock requiring pressor support with norepinephrine and vasopressin. He was weaned off norepinephrine on post-op day (POD)1, and vasopressin on POD 2. Approximately three hours after withdrawal of vasopressin support his urine output increased dramatically up to a peak of 350 cc/hour with a recorded 24hr urine volume of >5L. Concurrently, his serum sodium was found to have increased from 147 mmol/L to 173 mmol/L (n 135-145) over the course of 13 hours. Clinically, he became increasingly lethargic with abnormal eye movements. His sodium did not improve with fluid management with D5W. His other laboratory values included a urine osmolality of 141 mOsm/kg, urine sodium of 60 mmol/L and a peak serum sodium of 177mmol/L. He was administered 1mcg desmopressin and his D5W rate was increased. His urine output dropped gradually to ~150cc/hr, his serum sodium level started to trend down to 168 mmol/L and his urine osmolality increased to 439 mOsm/kg five hours after desmopressin administration, with improvement in mental status. The patient received a total of two doses of desmopressin and continued support with IV fluids. His sodium eventually normalized, and his polyuria did not return. Discussion: This patient’s clinical picture is consistent with tCDI secondary to discontinuation of vasopressin. Transient Central diabetes insipidus due to vasopressin withdrawal is a phenomenon that is not well understood, but there is a strong male preponderance, and it tends to occur more commonly in patients with underlying neurological conditions, as did our patient. Current proposed mechanisms include decreased production and release of exogenous ADH due to negative feedback, down regulation of the V2 receptors, and hypoperfusion to the posterior pituitary. This condition deserves more investigation to better understand the incidence, risk factors and pathophysiological mechanisms.

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