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==  
[[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 syndrome|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]], 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>
{| class="wikitable"
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Disease
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Causes
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Symptoms
! align="center" style="background:#4479BA; color: #FFFFFF;" + |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.
|
*[[Nausea]] / [[vomiting]]
*[[Cramps]]
*[[Depressed mood]]
*[[Irritability]]
*[[Confusion]]
*[[ Hallucinations]]
*[[Seizures]] ,[[stupor]] or [[coma ]]
|
*[[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}}
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[SIADH]]
| style="padding: 5px 5px; background: #F5F5F5;" |
*Excessive release of [[Vasopressin|antidiuretic hormone (ADH or vasopressin)]]  from the [[posterior pituitary]] gland or another source.
*[[Hyponatremia]]
*[[Fluid]] overload
*[[Hyponatremia]] <135 mmol/l
*Effective serum [[osmolality]] < 275 mOsm
*Urine [[sodium]] concentration > 40 mMol/l
*Plasma [[uric acid]] < 200
*Absence of [[edema]]-inducing diseases, such as [[heart failure]], [[liver cirrhosis]], and [[nephrotic syndrome]]
*Normal [[adrenal]] and [[thyroid]] function
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Weight loss]] (in case of [[malignancy]])
* History of head [[trauma]]
* History of medication intake
* Positive [[family history]]
|-
|-
|[[Cerebral salt wasting syndrome]]
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[Cerebral salt wasting syndrome]]
 
| style="padding: 5px 5px; background: #F5F5F5;" |
|[[ Cerebral salt wasting syndrome]] is defined as the[[ renal]] loss of [[sodium]] during intracranial disease leading to [[hyponatremia]] and a decrease in extracellular fluid volume.
*[[Hyponatremia]]
 
*Urine [[sodium]] concentration > 40 mMol/l
*[[Trauma]]
*[[Tumor]]
*[[Hematoma]]


|The patient is
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Hypovolemic]]  
*[[Hypovolemia]]
*[[Hyponatremia|Hyponatremic]]
*Intracranial [[diseases]], such as:
 
**[[Tumor]]
|Treatment is with adequate
**[[Trauma]]
*[[Hydration]] and
**[[Hematoma]]
*[[Sodium]] replacement
|-
|-
|[[Adrenal insufficiency]]
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[Adrenal insufficiency]]
 
| 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.
Adrenal insufficiency can be
*[[Primary]]
*[[Secondary]]
[[Tertiary]]
Common causes of primary adrenal insufficiency:  
*[[Autoimmune]]
*[[Iatrogenic]]
*[[Drugs]]
* [[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]]
*[[Weight loss]]
*[[Sparse axillary hair]]
*Sparse [[axillary]] hair
*[[Hyperpigmentation]]  
*[[Hyperpigmentation]]  
*[[Orthostatic hypotension]].
*[[Orthostatic hypotension]]
 
Acute [[addisonian]] crisis is characterized by:
*[[Fever]]  
*[[Fever]]  
*[[ Hypotension]]
*[[Hypotension]]
|The diagnosis of [[Addisons]] disease is made through rapid [[ACTH]] administration and measurement of [[cortisol]].
*[[Eosinophilia]]
*Lab findings include:
*[[Hyperkalemia]]  
*[[White blood cell]] count with moderate [[neutropenia]]
*[[Hypoglycemia]]
*[[lymphocytosis]]
*Morning low plasma [[cortisol]]
*[[ 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,measure [[cortisol]] level,then rapidly administer
*[[ Fluids]]
*[[ Hydrocortisone]] 
|-
|-
|[[Hypopituitarism]]
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[Hypopituitarism]]
|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]]
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[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:
* [[Fatigue]]
* [[Fatigue]]
* [[Weight loss]]
* [[Weight loss]]
Line 140: Line 71:
* [[Anemia]]
* [[Anemia]]
* [[Infertility]]
* [[Infertility]]
*[[ Cold insensitivity]].
* [[Cold intolerance]]
* [[Amenorrha]]
* [[Amenorrhea]]
*[[Inability to lactate]] in [[breast feeding]] women
* Inability to lactate in [[breast feeding]] women
* Decreased [[facial]] or[[ body hair]] in men
* Decreased [[facial]] or [[body hair]] in men
* [[Short stature]] in children
* [[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;" |[[Psychogenic polydipsia]]  
|Hypofunctioning of the thyroid gland due to multifactorial etiology ranging from congenital to [[autoimmune]] causes described below:
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Congenital]]
*[[Fluid]] overload
*[[Autoimmune]]
*[[Hyponatremia]]
*[[Drugs]]
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Post surgery]]
*Defect in the [[hypothalamus]]
*[[Post radiation]]
*[[Infiltrative]] e.g., amyloid
|
*[[ Fatigue]]
* [[Constipation]]
*[[ Dry skin]]
*[[ Weight gain]]
* [[Cold intolerance]]
*[[ Puffy face]]
*[[ Hoarseness]]
*[[ 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]]
| Also called as[[ primary polydipsia]] is characterized by[[ polyuria]] and [[polydipsia]]. Causes are:
* Defect in the [[hypothalamus]]
*Adverse effect of a [[medication]]
*Traumatic[[ brain]] injury
*[[Psychiatric]] disorders such as [[schizophrenia]]
|
*[[Polyuria]]
*[[Polyuria]]
*[[Polydipsia]]
*[[Polydipsia]]
Line 203: Line 88:
*[[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
|}
|}
==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.
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