Diabetes insipidus with impaired osmotic regulation in septo-optic dysplasia and agenesis of the corpus callosum

The clinical and endocrinological findings in 24 children with septo-optic dysplasia and/or agenesis of the corpus callosum are described with particular reference to posterior pituitary function. Nine had diabetes insipidus. The prevalence of diabetes insipidus was similar in children with complete and incomplete forms of septo-optic dysplasia. Maintenance of normal osmotic balance was very difficult in six of these children, even after the introduction of treatment with vasopressin, either as desmopressin, or lysine vasopressin spray in one of the early cases.     

Normal MR appearances of the posterior pituitary in central diabetes insipidus associated with septo-optic dysplasia

Magnetic resonance (MR) imaging of the pituitary in children with central diabetes insipidus usually shows absence of the normal high signal within the posterior gland. The high signal of the normal posterior pituitary is thought to be due to the presence of intra- cellular storage granules of vasopressin. MR imaging has been advocated as a useful investigation to aid in the distinction between central diabetes insipidus and other causes of thirst and polydipsia. We report the case of an infant with central diabetes insipidus in association with septo-optic dysplasia in whom MR imaging showed normal appearances of the posterior pituitary. The mechanism of central diabetes insipidus in this case may be related to a failure of hypothalamic function affecting osmoreception, rather than to a deficiency of vasopressin. Normal MR appearances of the pituitary do not exclude central diabetes insipidus in infants with midline cerebral malformations. Received: 20 November 1995 Accepted: 20 January 1996     

The endocrine spectrum of septo-optic dysplasia

Six children with septo-optic dysplasia were evaluated at the Children's Hospital of Philadelphia. There was a common history of young, nulliparous mothers. The clinical presentation of these children differed according to age of presentation and was a function of the degree and type of hypothalamic-pituitary and ophthalmologic impairment. Endocrine evaluation revealed four of six children to be growth hormone deficient, four of six to have hypothalamic hypothyroidism, and two of four to have elevated prolactin levels. One of the patients demonstrated adrenocorticotropic hormone deficiency, and one had diabetes insipidus. Neuroanatomic findings in the children were variable, but, in general, the rare syndrome did not carry as grave a morbidity as had been reported previously. Our data support a high degree of hypothalamic impairment in septo-optic dysplasia.     

Septo-Optic Dysplasia Presenting in Early Infancy

A case of septo-optic dysplasia (optic nerve hypoplasia and hypopituitarism with or without agenesis of the septum pellucidum) is described. The patient presented with diabetes insipidus in the neonatal period and was found to have associated deficiencies of adrenocortico-trophic hormone and growth hormone and optic nerve hypoplasia. The case illustrates the clinical features of this rare condition and some of the difficulties which may occur in managing diabetes insipidus in very young and ill infants. The most important clue to the diagnosis is the recognition of the optic nerve hypoplasia.     

DIABETES INSIPIDUS IN CHILDREN. Arginine-Vasopressin determination in plasma during short dehydration test

Abstract. Czernichow, P., Pomarède, R., Basmaciogullari, A. and Rappaport, R. (Department of Pediatrics and INSERM U 30, Hôpital des Enfants Malades, Paris, France). Arginine-Vasopressin determination in plasma during short dehydration test in children with Diabetes insipidus in children. I. Arginine-Vasopressin determination in plasma during short dehydration test. Acta Paediatr Scand, Suppl. 277: 64, 1979.—Plasma vasopressin as well as plasma and urinary osmolality are measured during an overnight dehydration test in vasopressin is undetectable. It is present in plasma from patients with partial diabetes insipidus but the level is not appropriate for plasma osmolality. In patients with polyuria of renal origin plasma vasopressin was significantly higher than in patients with neurogenic diabetes insipidus. Plasma vasopressin measurement is of diagnostic values in partial neurogenic diabetes insipidus and may be of considerable help to distinguish this group of patients from children with polyuria of renal origin.     

Sexual precocity in association with septo-optic dysplasia and hypothalamic hypopituitarism.

Sexual precocity in association with abnormalities of the central nervous system is well known, but its occurrence with hypothalamic hypopituitarism is most unusual. We report five females with septo-optic dysplasia, blindness, and multiple pituitary tropic hormone deficiencies: all were growth hormone and adrenocorticotropic hormone deficient; two had diabetes insipidus; one had sexual precocity, and one had early pubertal maturation, whereas three were prepubertal and responded to administration of synthetic gonadotropin-releasing hormone. These children retained ability to secrete gonadotropins despite the presence of anterior hypothalamic disease. Experimental data from primates plus our observations on these patients raise questions about the role of the anterior hypothalamus in gonadotropin secretion in man.     

TREATMENT OF DIABETES INSIPIDUS IN CHILDREN WITH DDAVP, A SYNTHETIC ANALOGUE OF VASOPRESSIN

The effects of a new, synthetic analogue of vasopressin, DDAVP (l-deamino-8-d-arginine vasopressin), was investigated in 10 children with diabetes insipidus due to deficient secretion of antidiuretic hormone. The lack of pressor activity, and the specific and long-lasting antidiuretic effect of this preparation was confirmed. During an observation period of 8–19 months it was found that intranasal administration of 1.25-10 μg of DDAVP twice daily was sufficient to normalize drinking and urine production in all the patients. No side effects were observed. It is concluded that DDAVP is a valuable alternative in the treatment of vasopressin sensitive diabetes insipidus in children, and that it is well suited for long-term use.     

Hypopituitarism associated with transsphenoidal meningoencephalocele

A 12-year-old boy with growth hormone deficiency and partial diabetes insipidus resulting from transsphenoidal meningoencephalocele and with eye abnormalities is described. Fifteen other patients with transsphenoidal meningoencepalocele have been reported. Hypothalamic-pituitary dysfunctions were diagnosed by endocrinological studies in seven cases. It is important to recognize transsphenoidal meningoencephalocele as a cause of hypopituitarism, since some cases may have gone unrecognized. The association of hypothalamic-pituitary dysfunction and a midline craniocerebral anomaly has been reported in patients with cleft lip and/or palate, septo-optic dysplasia, the holoprosencephalies, and Kallmann syndrome. However, there was no evidence of transsphenoidal meningoencephalocele in these disorders and this may be a different form of midline craniocerebral and midfacial anomaly.     

Diabetes insipidus: clinical and basic aspects

Water homeostasis in the body is finely balanced by the release of the antidiuretic hormone vasopressin and the stimulation of thirst. Vasopressin acts in the kidneys to concentrate urine and reduce plasma osmolality. Diabetes insipidus is a disorder of water balance characterized by a failure to concentrate urine. There are two types of diabetes insipidus: central and nephrogenic. Central diabetes insipidus is caused by insufficient production of vasopressin, while nephrogenic diabetes insipidus is caused by an impaired response of the kidneys to vasopressin. Patients with central diabetes insipidus respond to treatment with vasopressin or its synthetic analogue, desmopressin; however, caution should be utilized in treating infants with vasopressin or analogues-infants can be treated successfully with fluids alone. Treatment of nephrogenic diabetes insipidus involves removing the underlying cause, if possible, reducing solute load or therapy with a diuretic agent.     

Current perspective on the pathogenesis of central diabetes insipidus

Diabetes insipidus is a heterogeneous condition characterised by polyuria and polydipsia caused by a lack of secretion of vasopressin, its physiological suppression following excessive water intake, or kidney resistance to its action. The clinical and laboratory diagnosis is confirmed by standard tests, but recent advances in molecular biology and imaging techniques have shed new light on the pathophysiology of this disease. In many patients, central diabetes insipidus is caused by a germinoma or craniopharyngioma; Langerhans' cell histiocytosis and sarcoidosis of the central nervous system; local inflammatory, autoimmune or vascular diseases; trauma from surgery or accident; and, rarely, genetic defects in vasopressin biosynthesis inherited as autosomal dominant or X-linked recessive traits. Thirty to fifty percent of cases are considered idiopathic. Tumour-associated central diabetes insipidus is uncommon in children younger than 5 years old. Biopsy of enlarged pituitary stalk should be reserved for patients with hypothalamic-pituitary mass and progressive thickening of the pituitary stalk since spontaneous recovery may occur. Molecular biology in selected patients may identify those with apparently idiopathic diabetes insipidus carrying the vasopressin-neurophysin II gene mutation.     

Treatment of the young child with postoperative central diabetes insipidus

A continuous intravenous infusion of aqueous vasopressin (dosage range, 1.0 to 3.0 mU/kg/h) was administered to two patients (respective ages, 2 weeks and 3 years 1 month) who had postoperative central diabetes insipidus to determine if this mode of therapy is helpful in the very young patient. In both patients the polyuria and serum hyperosmolality were corrected. These findings suggest that an intravenous infusion of aqueous vasopressin can provide satisfactory control of the polyuria and electrolyte disturbances found in young children with acute postoperative central diabetes insipidus.     

Diabetes insipidus associated with Langerhans cell histiocytosis: Is it reversible?

Fourteen of 58 (24%) children with Langerhans cell histiocytosis (LCH) currently attending the Hospital for Sick Children (London) developed thirst and polyuria during the course of their disease. Three had single-system disease confined to bone, and 11 had multisystem disease. The median age at presentation of LCH was 2 years 0 months, and polyuria/polydipsia developed at a median age of 3 years 9 months (range 1 month before diagnosis of LCH to 4 years after diagnosis). Each child had a water deprivation test with measurement of urinary arginine vasopressin (AVP) to document diabetes insipidus. The doses of 1-desamino-8-D arginine vasopressin (DDAVP) required to control symptoms were compared at diagnosis and at a mean follow-up of 7 years 8 months. Local and systemic treatment was recorded. Ten of 14 children were shown to have “complete” diabetes insipidus, whilest the other four had “partial” diabetes insipidus. Seven children were treated with irradiation- with or without systemic chemotherapy, six with systemic chemotherapy only, and one with DDAVP replacement only. No child, including two with partial diabetes insipidus irradiated within 4 weeks of the onset of symptoms, lost symptoms of polyuria/polydypsia, and none was able to discontinue DDAVP replacement. One child treated with Etoposide showed a temporary rise in urinary AVP level to within the normal range but still needed DDAVP to control her symptoms. The mean doses of DDAVP at onset of diabetes insipidus and at follow-up were 9.3 μg and 18 μg daily, respectively. We conclude that the most appropriate treatment for reversing diabetes insipidus complicating Langerhans cell histiocytosis is yet to be determined. Precise documentation of posterior pituitary dysfunction, including measurement of urinary AVP levels, is essential if the effects of new forms of treatment are to be assessed accurately. Med. Pediatr. Oncol. 28:289–293. © 1997 Wiley-Liss, Inc.     

A vasopressin analogue in treatment of diabetes insipidus

Six children, 3 adolescents, and 3 adults with vasopressin-sensitive diabetes insipidus were treated with a vasopressin analogue, DDAVP (1-deamino-8-D-arginine vasopressin), at a daily dose ranging from 5 to 20 μg administered twice a day intranasally. The period of follow-up of these patients has been from 3 months to 1 year.DDAVP was effective in maintaining normal diuresis and normal urine concentration during both day and night. No local or vasopressor side effects were observed. Compared to other antidiuretic drugs, such as nasal pitressin powder, lysine-vasopressin nasal spray, or pitressin tannate injections, used previously by the patients, DDAVP proved to be superior in the control of the diabetes insipidus and in the subjective feeling of the patients.It is concluded that DDAVP is the drug of choice in the treatment of vasopressinsensitive diabetes insipidus.     

Diabetes insipidus in children. III. Anterior pituitary dysfunction in idiopathic types

Seventeen patients with idiopathic diabetes insipidus occurring in childhood were observed from 4 to 26 years (mean duration 15 1/2 years). The diagnosis of idiopathic diabetes insipidus was based on routine clinical examination and careful, repeated neuroradiologic investigations. Anterior pituitary dysfunction was present in some of these patients. Growth hormone deficiency was present in six children, insufficient thyroid stimulating hormone secretion after thyrotropin-releasing hormone stimulation was demonstrated in one, and abnormal response to a metyrapone test in two. Elevated prolactin and TSH values were present in three and two patients, respectively. Some of these abnormalities were transitory. The presence of anterior pituitary dysfunction in idiopathic diabetes insipidus indicates that the destructive process is not localized to vasopressin synthesizing cells but may also involve other parts of the hypothalamus.     

Nephrogenic Diabetes Insipidus: Effects of 3,5, Cyclic-adenosine Monophosphate

In view of the evidence that the actions of vasopressin are mediated by the release of adenosine 3,5, cyclic monophosphate (`cyclic-AMP''), the effects of this nucleotide were studied in 3 children with nephrogenic diabetes insipidus (NDI) who were insensitive to vasopressin.     

Evidence for intact V1-vasopressin receptors in congenital nephrogenic diabetes insipidus

The binding of tritium-labelled arginine vasopressin to human platelet vasopressin receptors was investigated in patients with congenital nephrogenic diabetes insipidus. Binding characteristics, that is receptor affinity and the maximum number of binding sites, were not significantly different from those found in normal control individuals. The findings confirm the concept of intact V₁ receptors in congenital nephrogenic diabetes insipidus. The defect in nephrogenic diabetes insipidus apparently only affects the cyclic adenosine monophosphate dependent V₂ receptors.     

Septo-optic dysplasia and growth hormone deficiency: accelerated pubertal maturation during GH therapy

We report four patients (three male, one female) with septo-optic dysplasia and growth hormone deficiency. All had GH therapy for a period of four to eight years until reaching final height. In all four cases bone maturation during puberty was accelerated (1.4 to 1.9 "years"/year), resulting in a final height which was clearly below the predicted height. The progress of pubertal stages was very short in all patients. In three patients TSH and prolactin release after TRH stimulation were increased. These data support a hypothalamic original of the endocrine disorder. Insufficient GH release, even after repeated GHRH stimulation, is in contrast to this assumption. In one case there was a late manifestation of neurohormonal diabetes insipidus, which indicates the possibility of later disease progression. MR imaging of the brain demonstrated variable malformation of the septum pellucidum, chiasma and nervus opticus or the pituitary gland, respectively.     

Diabetes insipidus, diabetes mellitus, optic atrophy, and deafness. 3 cases of 'DIDMOAD' syndrome

Three children with diabetes insipidus, diabetes mellitus, optic atrophy, and high-tone deafness were shown to lack vasopressin, indicative of degeneration of the cells of the hypothalamic supraoptic nuclei. The syndrome being due to a single gene defect, inherited as an autosomal recessive, is therefore likely to be the result of an inborn error of metabolism with variable periods of latency in those affected.     

Growth Response in the First Year of Growth Hormone Treatment in Prepubertal Children with Organic Growth Hormone Deficiency: a Comparison with Idiopathic Growth Hormone Deficiency

ABSTRACT. Patients in the Kabi International Growth Study (KIGS) up to 1st January 1990 who had organic growth hormone deficiency (OGHD) were identified. They accounted for 21% of all patients with growth hormone deficiency (GHD). Diagnostic categories within the OGHD group included septo-optic dysplasia, postnatal trauma, craniopharyngioma, other cranial tumours, and following acute leukaemia. Features at presentation and during the first year of hGH treatment were compared with those of children with idiopathic growth hormone deficiency (IGHD). Ninety prepubertal children with OGHD were selected for comparison of observed first-year height velocity (HV) with predicted values based on those observed in 257 children with IGHD. Those with septo-optic dysplasia, postnatal trauma and craniopharyngioma responded as predicted, whereas those with other cranial tumours appeared to grow less well than predicted. Glucocorticoid treatment did not affect response, but previous cranial or craniospinal irradiation was found to be associated with an observed HV which was significantly less than predicted.     

Continuous vasopressin replacement in diabetes insipidus.

Five children who developed diabetes insipidus as a manifestation of severe brain injury received continuous intravenous treatment with a solution containing both aqueous vasopressin and appropriate crystalloid replacement. Polyuria, hypernatraemia, and decreased urine osmolalities were safely corrected in all patients within eight to 28 hours.