Syndrome of inappropriate antidiuretic hormone differential diagnosis: Difference between revisions

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{{Syndrome of inappropriate antidiuretic hormone}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Syndrome_of_inappropriate_antidiuretic_hormone]]
{{CMG}}; {{AE}} {{Vbe}}
{{CMG}}; {{AE}}{{Vbe}}


==Overview==
==Overview==  
[[Syndrome of inappropriate antidiuretic hormone secretion (SIADH)]] was initially described by Leaf and Mamby. SIADH consists of[[ hyponatremia]], inappropriately elevated urine osmolality, excessive urine sodium and decreased serum osmolality in a euvolemic patient without edema. These findings should occur in the absence of diuretic treatment with normal [[cardiac, renal]], [[adrenal]], hepatic and [[thyroid]] function. Hyponatremia occurs in about 30% of hospitalized patients and SIADH is the most frequent cause of hyponatremia. Differentiating hyponatremia due to SIADH from other causes of hyponatremia becomes essential to evaluate the treatment plan. [[Syndrome of inappropriate antidiuretic hormone]] must be differentiated from [[cerebral salt wasting]] , [[adrenal insufficiency]], [[hypopituitarism]], [[hypothyroidism]],[[psychogenic polydipsia]]
Syndrome of inappropriate antidiuretic hormone (SIADH) must be differentiated from other causes of [[hyponatremia]], such as [[cerebral salt wasting syndrome]], [[adrenal insufficiency]], [[hypopituitarism]], and [[psychogenic polydipsia]].
 
==Differentiating Syndrome of Inappropriate Antidiuretic Hormone from other Diseases==
==Differentiating Syndrome of inappropriate antidiuretic hormone from other Diseases==
[[SIADH]] must be differentiated from cerebral salt wasting, [[ adrenal insufficiency]], [[hypopituitarism]], [[hypothyroidism]], and [[psychogenic polydipsia]].<ref name="pmid27936532">{{cite journal |vauthors=Heidelbaugh JJ |title=Endocrinology Update: Hypopituitarism |journal=FP Essent |volume=451 |issue= |pages=25–30 |year=2016 |pmid=27936532 |doi= |url=}}</ref><ref name="pmid15241506">{{cite journal |vauthors=Hammer F, Arlt W |title=[Hypopituitarism] |language=German |journal=Internist (Berl) |volume=45 |issue=7 |pages=795–811; quiz 812–3 |year=2004 |pmid=15241506 |doi=10.1007/s00108-004-1216-5 |url=}}</ref><ref name="pmid25712898">{{cite journal |vauthors=de Fost M, Oussaada SM, Endert E, Linthorst GE, Serlie MJ, Soeters MR, DeVries JH, Bisschop PH, Fliers E |title=The water deprivation test and a potential role for the arginine vasopressin precursor copeptin to differentiate diabetes insipidus from primary polydipsia |journal=Endocr Connect |volume=4 |issue=2 |pages=86–91 |year=2015 |pmid=25712898 |pmc=4401105 |doi=10.1530/EC-14-0113 |url=}}</ref>
SIADH must be differentiated from [[cerebral salt wasting]], [[ adrenal insufficiency]], [[hypopituitarism]], [[hypothyroidism]], [[psychogenic polydipsia]]<ref name="pmid27936532">{{cite journal |vauthors=Heidelbaugh JJ |title=Endocrinology Update: Hypopituitarism |journal=FP Essent |volume=451 |issue= |pages=25–30 |year=2016 |pmid=27936532 |doi= |url=}}</ref><ref name="pmid15241506">{{cite journal |vauthors=Hammer F, Arlt W |title=[Hypopituitarism] |language=German |journal=Internist (Berl) |volume=45 |issue=7 |pages=795–811; quiz 812–3 |year=2004 |pmid=15241506 |doi=10.1007/s00108-004-1216-5 |url=}}</ref><ref name="pmid25712898">{{cite journal |vauthors=de Fost M, Oussaada SM, Endert E, Linthorst GE, Serlie MJ, Soeters MR, DeVries JH, Bisschop PH, Fliers E |title=The water deprivation test and a potential role for the arginine vasopressin precursor copeptin to differentiate diabetes insipidus from primary polydipsia |journal=Endocr Connect |volume=4 |issue=2 |pages=86–91 |year=2015 |pmid=25712898 |pmc=4401105 |doi=10.1530/EC-14-0113 |url=}}</ref>
 
*
{| class="wikitable"
!
Disease
!Causes
!Symptoms
!Diagnosis and treatment
|- Diagnostic criteria of SIADH include:
 
|SIADH
|SIADH is a syndrome characterized by excessive release of [[Vasopressin|antidiuretic hormone]] (ADH or vasopressin) from the [[posterior pituitary]] gland or another source. The result is [[hyponatremia]], and sometimes fluid overload.
|Symptoms are variable. Ranging from
*[[Nausea/vomiting]]
*[[Cramps]]
*[[Depressed mood]]
*[[Irritability]]
*[[Confusion]]
*[[ Hallucinations]].
*[[Seizures]] ,[[stupor]] or [[coma ]]may result(in severe cases)
|[[Hyponatremia ]] <135 mmol/l
 
*[[Decreased effective serum osmolalit]]y<275mosm
 
*[[Urine sodium concentration]]>40mmol/litre
 
*[[Plasma uric acid]] <200;FeUrate>12%
 
*Absence of edematous disease like[[ cardiac failure]], [[liver cirrhosis]],[[ nephrotic syndrome]].
 
*Normal [[adrenal]] and thyroid function


{| style="border: 0px; font-size: 90%; margin: 3px; width: 1000px" align="center"
| valign="top" |
|+
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Differential Diagnosis}}
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Similar Features}}
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Differentiating Features}}
|-
|-
|Cerebral salt wasting
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[SIADH]]
 
| style="padding: 5px 5px; background: #F5F5F5;" |
| Cerebral salt wasting is defined as the renal loss of sodium during intracranial disease leading to hyponatremia and a decrease in extracellular fluid volume.
*Excessive release of [[Vasopressin|antidiuretic hormone (ADH or vasopressin)]]  from the [[posterior pituitary]] gland or another source.  
 
*[[Hyponatremia]]
*[[Polyuria]]
*[[Fluid]] overload
*[[polydipsia]]
*[[Hyponatremia]] <135 mmol/l
*[[Lightheadedness]]
*Effective serum [[osmolality]] < 275 mOsm
*[[Muscle cramps]]
*Urine [[sodium]] concentration > 40 mMol/l
*[[Orthostatic hypotension]]
*Plasma [[uric acid]] < 200
*[[Headaches]]
*Absence of [[edema]]-inducing diseases, such as [[heart failure]], [[liver cirrhosis]], and [[nephrotic syndrome]]
 
*Normal [[adrenal]] and [[thyroid]] function
|The patient is
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Hypovolemic]]  
* [[Weight loss]] (in case of [[malignancy]])
*[[Hyponatremic]].
* History of head [[trauma]]
 
* History of medication intake
|Treatment is with adequate
* Positive [[family history]]
*[[Hydration]] and
*[[Sodium]] replacement.
|-
|-
|[[Adrenal insufficiency]]
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[Cerebral salt wasting syndrome]]
 
| style="padding: 5px 5px; background: #F5F5F5;" |
|[[Adrenal insufficiency]] ranges from mild nonspecific symptoms to life-threatening [[shock]] like condition.
*[[Hyponatremia]]
An important distinction in these patients is the presence of[[ mineralocorticoid deficiency]]. Those with [[secondary]] or [[tertiary adrenal insufficiency]] will typically have preserved[[ mineralocorticoid]] function due to the separate feedback systems.
*Urine [[sodium]] concentration > 40 mMol/l
Adrenal insufficiency can be [[primary]], [[secondary]] or[[ tertiary]].
 
Common causes of primary adrenal insufficiency:  
*[[Autoimmune]]
*[[Iatrogenic]]
*[[Drugs]]
*Others- [[adrenal hemorrhage]], [[cancer]],[[ infection]].
*[[congenital]].
Secondary adrenal insufficiency refers to decreased [[adrenocorticotropic hormone]] (ACTH) stimulation of the [[adrenal cortex]] and therefore does not affect [[aldosterone levels]]. Most common causes are:
*[[Traumatic brain injury (TBI) ]]
*[[Panhypopituitarism]] 
Tertiary adrenal insufficiency refers to decreased [[hypothalamic]] stimulation of the pituitary to secrete [[ACTH]].
Exogenous[[ steroid]] administration is the most common cause of tertiary adrenal insufficiency.
|
* Fatigue
* Muscle weakness
* Loss of appetite
* Weight loss
* Abdominal pain
*Diarrhea
*Vomiting


Chronic disease is characterized by
| style="padding: 5px 5px; background: #F5F5F5;" |
*Weight loss
*[[Hypovolemia]]
*Sparse axillary hair
*Intracranial [[diseases]], such as:
*Hyperpigmentation of the skin
**[[Tumor]]
*[[Orthostatic hypotension]].
**[[Trauma]]
 
**[[Hematoma]]
Acute addisonian crisis is characterized by [[fever]] and[[ hypotension]]. A low sodium with a high potassium level and mild [[acidosis]] are also present.
|The diagnosis of Addisons disease is made through rapid [[ACTH]] administration and measurement of [[cortisol]].Lab findings include:
*White blood cell count with moderate neutropenia,lymphocytosis,and eosinophilia
*Elevated serum[[ potassium]] and [[urea nitrogen]]
*Low sodium
*Low blood glucose
* Morning low plasma cortisol.
The definitive diagnosis is the [[cosyntropin]] or [[ACTH]] stimulation test. A[[ cortisol]] level is obtained before and after administering ACTH. A normal person should show a brisk rise in [[cortisol]] level after [[ACTH]] administration.
 
 
Management: The management of Addison disease involves:
*Gluocorticoid
*Mineralocorticoid
*Sodium chloride replacement.
Adrenal crisis:
*In adrenal crisis,get a cortisol level,then rapidly administer fluids and hydrocortisone.( Adrenal crisis may occur in previously undiagnosed patient with adrenal insufficiency who has
*Undergone surgery
*Serious infection
*Any major stressful conditions.
*Bilateral adrenal infarction or hemorrhage
*Patient who is abruptly withdrawn from chronic glucocorticoid therapy
|-
|-
|Hypopituitarism:
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[Adrenal insufficiency]]
|Hypopituitarism is defined as the partial or complete loss of anterior pituitary function that can result from acquired or congenital causes.
| style="padding: 5px 5px; background: #F5F5F5;" |
Etiology is as follows:
*[[Hyponatremia]]
*Pituitary tumors
*Sellar tumors
*Head trauma
*Infection
*Empty sella
*Infiltration
*Idiopathic
*Congenital
|
Signs and symptoms of hypopituitarism vary, depending on the deficient


[[hormone ]] and severity of the disorder,some of the symptoms may be as follows:
| style="padding: 5px 5px; background: #F5F5F5;" |
* Fatigue
*[[Weight loss]]
* Weight loss
*Sparse [[axillary]] hair
* Decreased libido
*[[Hyperpigmentation]]  
* Decreased appetite
*[[Orthostatic hypotension]]
* Facial puffiness
*[[Fever]]  
* Anemia
*[[Hypotension]]
* Infertility
*[[Eosinophilia]]
* Cold insensitivity.
*[[Hyperkalemia]]  
* Amenorrha
*[[Hypoglycemia]]
*Inability to lactate in breast feeding women
*Morning low plasma [[cortisol]]
* Decreased facial or body hair in men
* Short stature in children
|The diagnosis is based on detailed investigation of symptoms of target endocrine gland function relative to the corresponding pituitary hormone deficiency. The clinical manifestations of[[ hypopituitarism]] result from the degree of the specific hormone deficiency.
A thorough and longitudinal history and physical examination, including visual field testing, are important.
Hypopituitarism may involve from one to all endocrine axes regulated by the pituitary
In order of frequency: [[growth hormone]] deficiency>[[secondary hypogonadism]]>[[secondary hypothyroidism]]>[[secondary adrenal failure]]).
The treatment of permanent hypopituitarism consists of replacement of the peripheral hormones
*[[hydrocortisone]]  
*[[DHEA]]  
*[[Thyroxine]]
*[[Testosterone]] or [[oestradiol]]
*[[ Growth hormone]]
*[[Surgery]] and/or
*[[ Radiotherapy]] to restore normal [[endocrine]] function and quality of life.
Patients with hypopituitarism require lifelong monitoring of serum hormone levels and symptoms of hormone deficiency or excess. Long-term care and monitoring of patients with hypopituitarism requires a experienced [[endocrinologist]].
|-
|-
|Hypothyroidism
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[Hypopituitarism]]
|Hypofunctioning of the thyroid gland due to multifactorial etiology ranging from congenital to autoimmune causes described below:
| style="padding: 5px 5px; background: #F5F5F5;" |
*Congenital
*[[Hyponatremia]]
*Autoimmune
| style="padding: 5px 5px; background: #F5F5F5;" |
*Drugs
* [[Fatigue]]
*Post surgery
* [[Weight loss]]
*Post radiation
* Decreased [[libido]]
*Infiltrative e.g., amyloid
* Decreased [[appetite]]
|
* Facial [[puffiness]]
* Fatigue
* [[Anemia]]
* Constipation
* [[Infertility]]
* Dry skin
* [[Cold intolerance]]
* Weight gain
* [[Amenorrhea]]
* Cold intolerance
* Inability to lactate in [[breast feeding]] women
* Puffy face
* Decreased [[facial]] or [[body hair]] in men
* Hoarseness
* [[Short stature]] in children
* Muscle weakness
* Elevated blood cholesterol level
* Bradycardia
* Myopathy
* Depression
* Impaired memory
| Diagnosis of [[hypothyroidism]] is based on [[blood]] tests:
*T3(triiodothyronine)
*T4(Thyroxine) and
*TSH (thyroid stimulating hormone).
Signs and symptoms are neither sensitive nor specific for the diagnosis. TSH is the most sensitive tool for screening,diagnosis and treatment follow up, when pituitary is normal.
*The drug of choice for treatment is [[Levothyroxine]].
|-
|-
|[[Psychogenic polydipsia]]  
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[Psychogenic polydipsia]]  
| Also called as[[ primary polydipsia]] is characterized by[[ polyuria]] and [[polydipsia]]. Causes could be:
| style="padding: 5px 5px; background: #F5F5F5;" |
* Defect in the [[hypothalamus]]
*[[Fluid]] overload
*Adverse effect of a [[medication]]
*[[Hyponatremia]]
*Traumatic brain injury
| style="padding: 5px 5px; background: #F5F5F5;" |
*Psychiatric disorders such as [[schizophrenia]]
*Defect in the [[hypothalamus]]
|*[[Polyuria]]
*[[Polyuria]]
*[[Polydipsia]]
*[[Polydipsia]]
*[[Confusion]]
*[[Confusion]]
*[[Lethargy]]
*[[Lethargy]]
*[[Psychosis]]
*[[Psychosis]]
*[[Seizures]] and
*[[Seizures]]  
*Sometimes, even [[Death]].
|Evaluation of[[ psychiatric]] patients with polydipsia warrants a comprehensive evaluation for other medical causes of polydipsia, polyuria,[[ hyponatremia]], and the syndrome of inappropriate secretion of antidiuretic hormone. The management strategy in[[ psychiatric]] patients should include:
 
*[[Fluid]] restriction and[[ behavioral]] and [[pharmacologic]] modalities.
*The water deprivation test is the [[gold standard]] test to differentiate central or [[nephrogenic diabetes insipidus]] (DI) from [[primary polydipsia]] (PP) in patients with polyuria and polydipsia. In healthy subjects, water deprivation causes the plasma [[osmolality]] to rise above 280–290 mOsmol/kg, which leads to the release of [[AVP]] into the circulation. In the collecting ducts of the kidney, AVP binds to the vasopressin type 2 receptor and this is followed by expression of aquaporin 2 channels. This results in increased [[water retention]] with a rise in urine[[ osmolality]] to a maximum of 1000–1200 mOsmol/kg and restoration of plasma osmolality toward the [[reference]] range.
|}
|}
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


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Latest revision as of 00:22, 30 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2]

Overview

Syndrome of inappropriate antidiuretic hormone (SIADH) must be differentiated from other causes of hyponatremia, such as cerebral salt wasting syndrome, adrenal insufficiency, hypopituitarism, and psychogenic polydipsia.

Differentiating Syndrome of Inappropriate Antidiuretic Hormone from other Diseases

SIADH must be differentiated from cerebral salt wasting, adrenal insufficiency, hypopituitarism, hypothyroidism, and psychogenic polydipsia.[1][2][3]

Differential Diagnosis Similar Features Differentiating Features
SIADH
Cerebral salt wasting syndrome
Adrenal insufficiency
Hypopituitarism
Psychogenic polydipsia

References

  1. Heidelbaugh JJ (2016). "Endocrinology Update: Hypopituitarism". FP Essent. 451: 25–30. PMID 27936532.
  2. Hammer F, Arlt W (2004). "[Hypopituitarism]". Internist (Berl) (in German). 45 (7): 795–811, quiz 812–3. doi:10.1007/s00108-004-1216-5. PMID 15241506.
  3. de Fost M, Oussaada SM, Endert E, Linthorst GE, Serlie MJ, Soeters MR, DeVries JH, Bisschop PH, Fliers E (2015). "The water deprivation test and a potential role for the arginine vasopressin precursor copeptin to differentiate diabetes insipidus from primary polydipsia". Endocr Connect. 4 (2): 86–91. doi:10.1530/EC-14-0113. PMC 4401105. PMID 25712898.