Long-term low-dose tolvaptan efficacy and safety in SIADH.

PURPOSE: Tolvaptan, a selective vasopressin V2-receptor antagonist, is approved for the treatment of SIADH-related hyponatremia, but its use is limited. The starting dose is usually 15 mg/day, but recent clinical experience suggests a lower starting dose (<15 mg/day) to reduce the risk of sodium overcorrection. However, long-term low-dose efficacy and safety has not been explored, so far. Aim of our study is to characterize safety and efficacy of long-term SIADH treatment with low-dose Tolvaptan. METHODS: We retrospectively evaluated 11 patients receiving low-dose Tolvaptan (<15 mg/day) for chronic SIADH due to neurological, idiopathic and neoplastic causes. Plasma sodium levels were measured before and 1, 3, 5, 15 and 30 days after starting Tolvaptan and then at 3-month intervals. Anamnestic and clinical data were collected. RESULTS: Mean time spanned 27.3 ± 29.8 months (range 6 months-7 years). Mean plasma sodium levels were within normal range 1, 3 and 6 months after starting Tolvaptan as well as after 1, 2, 3, 5 and 7 years of therapy. Neither osmotic demyelination syndrome nor overcorrection were observed. Plasma sodium levels normalization was associated with beneficial clinical effects. Neurological patients obtained seizures disappearance, improvement in neurological picture and good recovery from rehabilitation. Neoplastic patients were able to start chemotherapy and improved their general condition. Patients did not show hypernatremia during long-term follow-up and reported mild thirst and pollakiuria. CONCLUSIONS: The present study shows that long-term low-dose Tolvaptan is safe and effective in SIADH treatment. No cases of overcorrection were documented and mild side effects were reported.

Pituitary apoplexy and COVID-19 vaccination: a case report and literature review.

A 50-year-old man was admitted to our hospital for vomit, nausea, diplopia, and headache resistant to analgesic drugs. Symptoms started the day after his third COVID-19 mRNA vaccine (Moderna) whereas SARS-CoV-2 nasal swab was negative. Pituitary MRI showed recent bleeding in macroadenoma, consistent with pituitary apoplexy. Adverse Drug Reaction was reported to AIFA (Italian Medicines Agency).A stress dexamethasone dose was administered due to the risk of adrenal insufficiency and to reduce oedema. Biochemistry showed secondary hypogonadism; inflammatory markers were elevated as well as white blood cells count, fibrinogen and D-dimer. Pituitary tumour transsphenoidal resection was performed and pathology report was consistent with pituitary adenoma with focal haemorrhage and necrosis; we found immunohistochemical evidence for SARS-CoV-2 proteins next to pituitary capillaries, in the presence of an evident lymphocyte infiltrate.Few cases of pituitary apoplexy after COVID-19 vaccination and infection have been reported. Several hypotheses have been suggested to explain this clinical picture, including cross-reactivity between SARS-CoV-2 and pituitary proteins, COVID-19-associated coagulopathy, infection-driven acutely increased pituitary blood demand, anti-Platelet Factor 4/heparin antibodies development after vaccine administration. Ours is the first case of SARS-CoV-2 evidence in pituitary tissue, suggesting that endothelial infection of pituitary capillaries could be present before vaccination, possibly due to a previous asymptomatic SARS-CoV-2 infection. Our case underlines that SARS-CoV-2 can associate with apoplexy by penetrating the central nervous system, even in cases of negative nasal swab. Patients with pituitary tumours may develop pituitary apoplexy after exposure to SARS-CoV-2, therefore clinicians should be aware of this risk.

Bone health in adolescence.

Adolescence is a fundamental period for the formation of the skeleton, because is the stage in which bones grow more in both size and strength, laying a solid foundation for the future health of the skeleton. Any condition interfering with optimal peak bone mass accrual can increase fracture risk later in life. Up to 80% of peak bone mass is genetically determined while the remaining 20% is modulated by environmental factors that, if deleterious, may result in low bone mineral density (BMD) and an increased risk of fracture. The preferred test to assess bone health is dual-energy x-ray absorptiometry (spine or total body less head) using Z scores instead of T scores, even though in short stature or growth delay, should be used the height Z-score. The correction of risk factors is the first treatment for low BMD in children and adolescents. It's necessary having a correct lifestyle for preserving bone health: a proper nutrition, an adequate physical weight-bearing activity and avoidance of alcohol intake and tobacco smoke. Bisphosphonates could be used in children who sustained osteoporotic fractures, impairing quality of life, when spontaneous recovery is low for the persistence of osteoporosis risk factors. This clinical review discusses factors affecting bone health during childhood and adolescence and deals with diagnosis and treatment of low bone mass or osteoporosis in this age group.

Spontaneously reversible adrenal nodules in primary diffuse large B-cell testicular lymphoma mimicking an extranodal involvement: A case report.

In the staging of cancer patients, transient and spontaneously reversible bilateral adrenal hypertrophy may mimic a secondary localization of the disease. We discuss the case of an 82-year-old male patient with suspected testicular neoplasia in which abdominal CT examination reveals the onset of a bilateral macronodular adrenal enlargement, suggesting the diagnostic hypothesis of primary testicular neoplasia with secondary adrenal localization. The subsequent 18FDG-PET/CT study showed hyper-metabolism of the testicular mass, while the adrenal glands, surprisingly, did not show increased uptake of the radiotracer. After right orchifunicolectomy, primary testicular diffuse large B-cell lymphoma was diagnosed. The subsequent staging PET/CT study with iodine contrast medium, three months after the first CT examination, showed spontaneous complete regression of the adrenal hypertrophy without any use of drug therapy. The differential diagnosis of this finding considered the lack of hypermetabolism and the densitometric characteristics of the adrenal glands, the absence of possible pharmacological interactions throughout the time of the diagnostic procedures, and the available clinical-laboratory data. By excluding the main causes of adrenal hypertrophy, the most likely diagnostic hypothesis was transient adrenal hypertrophy due to stress induced by testicular lymphoma, meaning by stress a disturbance not only emotional but also an alteration of organic homeostasis. Our case suggests that the analysis of adrenal lesions appeared in cancer patients should take into account non-metastatic conditions that must be studied with a multimodal approach and with serial investigations.