Syndrome of inappropriate antidiuretic hormone differential diagnosis

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

==Overview==]] SIADH consists ofhyponatremia, inappropriately elevatedurine 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

Differentiating Syndrome of inappropriate antidiuretic hormone from other Diseases

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

Disease

Causes Symptoms Diagnosis and treatment
SIADH SIADH is a syndrome characterized by excessive release of 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
  • Normal adrenal and thyroid function
Cerebral salt wasting Cerebral salt wasting is defined as the renal loss of sodium during intracranial disease leading to hyponatremia and a decrease in extracellular fluid volume. The patient is Treatment is with adequate
Adrenal insufficiency Adrenal insufficiency ranges from mild nonspecific symptoms to life-threatening shock like condition.

An important distinction in these patients is the presence ofmineralocorticoid deficiency. Those with secondary or tertiary adrenal insufficiency will typically have preservedmineralocorticoid function due to the separate feedback systems. Adrenal insufficiency can be primary, secondary ortertiary.

Common causes of primary adrenal insufficiency:

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:

Tertiary adrenal insufficiency refers to decreased hypothalamic stimulation of the pituitary to secrete ACTH. Exogenoussteroid 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

Acute addisonian crisis is characterized by fever andhypotension. 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 serumpotassium and urea nitrogen
  • Low sodium
  • Low blood glucose
  • Morning low plasma cortisol.

The definitive diagnosis is the cosyntropin or ACTH stimulation test. Acortisol 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: Hypopituitarism is defined as the partial or complete loss of anterior pituitary function that can result from acquired or congenital causes.

Etiology is as follows:

  • 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:

  • Fatigue
  • Weight loss
  • Decreased libido
  • Decreased appetite
  • Facial puffiness
  • Anemia
  • Infertility
  • Cold insensitivity.
  • Amenorrha
  • Inability to lactate in breast feeding women
  • 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 ofhypopituitarism 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

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 Hypofunctioning of the thyroid gland due to multifactorial etiology ranging from congenital to autoimmune causes described below:
  • Congenital
  • Autoimmune
  • Drugs
  • Post surgery
  • 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.

Psychogenic polydipsia Also called asprimary polydipsia is characterized bypolyuria and polydipsia. Causes could be: Evaluation ofpsychiatric 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 inpsychiatric patients should include:

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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