Syndrome of inappropriate secretion of antidiuretic hormone as an initial sign of primary central nervous system lymphomas in the hypothalamus.

BACKGROUND: Primary central nervous system lymphoma (PCNSL) rarely originates in the hypothalamus. Hypothalamic PCNSL can present with various symptoms specific to dysfunction of the hypothalamus, including consciousness disturbance, cognitive impairment, hypopituitarism, and diabetes insipidus (DI). However, it remains unclear whether syndrome of inappropriate secretion of antidiuretic hormone (SIADH) can present as an initial sign of hypothalamic PCNSL. METHODS: Ninety-nine patients with PCNSL were diagnosed between January 2006 and December 2020 at our institutes. The initial symptoms and signs, hypothalamic-pituitary functions, serum sodium (Na) value, Karnofsky Performance Status (KPS) score on admission, and duration from onset to diagnosis were retrospectively investigated from the medical charts. RESULTS: Eight and 91 patients had hypothalamic PCNSL (hypothalamic group) and PCNSL located in other regions (control group), respectively. Patients' pathological diagnoses were diffuse large B-cell lymphoma (97 patients) and intravascular lymphoma (two patients). Six patients presented with hyponatremia derived from SIADH or suspected SIADH, and one presented with DI. Statistically significant differences between the hypothalamic and control groups were detected only in the preoperative serum Na values and KPS scores. CONCLUSION: SIADH can be an initial presentation of hypothalamic PCNSL. Early detection of hypothalamic PCNSL from SIADH may lead to proper management and improved prognosis.

Jean Camus and Gustave Roussy: pioneering French researchers on the endocrine functions of the hypothalamus.

At the beginning of the twentieth century, the hypothalamus was known merely as an anatomical region of the brain lying beneath the thalamus. An increasing number of clinicopathological reports had shown the association of diabetes insipidus and adiposogenital dystrophy (Babinski-Fröhlich's syndrome), with pituitary tumors involving the infundibulum and tuber cinereum, two structures of the basal hypothalamus. The French physicians Jean Camus (1872-1924) and Gustave Roussy (1874-1948) were the first authors to undertake systematic, controlled observations of the effects of localized injuries to the basal hypothalamus in dogs and cats by pricking the infundibulo-tuberal region (ITR) with a heated needle. Their series of surgical procedures, performed between 1913 and 1922, allowed them to claim that both permanent polyuria and adiposogenital dystrophy were symptoms caused by damage to the ITR. Their results challenged the dominant doctrine of hypopituitarism as cause of diabetes insipidus and adiposogenital dystrophy that derived from the experiments performed by Paulescu and Cushing a decade earlier. With their pioneering research, Camus and Roussy influenced the experimental work on the hypothalamus performed by Percival Bailey and Frederic Bremer at Cushing's laboratory, confirming the hypothalamic origin of these symptoms in 1921. More importantly, they provided the foundations for the physiological paradigm of Neuroendocrinology, the hypothalamus' control over the endocrine secretions of the pituitary gland, as well as over water balance and fat metabolism. This article aims to credit Camus and Roussy for their groundbreaking, decisive contributions to postulate the hypothalamus being the brain region in control of endocrine homeostasis and energy metabolism.

A case of Langerhans cell histiocytosis with thyroid involvement.

Thyroid involvement with Langerhans cell histiocytosis (LCH) is very rare. We report here the case of a 15-year-old female patient with LCH affecting the thyroid gland. She was referred to the department of pediatric endocrinology for secondary amenorrhea. Prior to the diagnosis of LCH, the patient had symptoms of diabetes insipidus (DI) and amenorrhea. The mean time from symptom onset to diagnosis was 2 years. On physical examination the patient had grade 2 goiter, and ultrasound showed bilateral multiple hypoechoic nodules and thyroid heterogeneity. Biochemical analysis indicated central diabetes insipidus and panhypopituitarism. Magnetic resonance imaging (MRI) demonstrated a mass lesion involving the hypothalamus, which appeared iso- to hypo-intense on T2-weighted images and had an intense postcontrast enhancement on T1-weighted images. Nodular goiter coinciding with a hypothalamic mass suggested LCH, and an excisional biopsy was performed. Histological evaluation of the thyroid gland revealed extensive involvement by LCH, and this was confirmed by immunohistochemical analysis showing S-100 protein and CD1a positive Langerhans cells that were weakly positive for CD68. LCH should be considered in the differential diagnosis of a diffusely enlarged firm and irregular thyroid gland and posterior or anterior pituitary dysfunction.

[Clinical characteristics of 7 patients with gestational diabetes insipidus].

OBJECTIVE: To investigate the clinical feature, treatment and prognosis of both the mother and the fetus with gestational diabetes insipidus. METHODS: A total of 7 cases of gestational diabetes insipidus collected in the First Affiliated Hospital of Wenzhou Medical College, Wenzhou Combination of Traditional Chinese Medicine with Western Medicine Hospital, and Zhejiang Taizhou Hospital from June 1993 to June 2006 were analyzed retrospectively. RESULTS: Seven cases symptoms all characterized by excessive thirst polydipsia and polyuria. The average 24 h urinary output was between 11 L to 13 L and manifested of hypobaricuria. After effective treatment (three cases were treated with 1-deamino-8-D-arginine vasopressin, another three patients were managed with hydrochlorothiazide, and the last one was cured with antisterone), seven patients with gestational diabetes insipidus did not have any severe consequences. Their symptoms of excessive thirst, polyuria, and polydypsia disappeared from 7 days to 3 months after parturition. Urinary volume returned to normal standard of 1000-2000 ml during 24 hours. Specific gravity of urine recovered normally between a range 1.015-1.025 and serum sodium recovered between 135-147 mmol/L. The average duration of illness was 52 days. Eight newborn infants survived. Two of them were sent to neonatal intensive care unit for treatment. One was because of premature delivery caused by antepartum eclampsia, and the other case was one of the twins who had hydronephrosis. The baby of the first case left hospital after 3 weeks' treatment. The latter one's symptom disappeared 2 weeks after delivery. No obvious symptom was discovered among all the babies through follow-up telephone calls 42 days after childbirth. CONCLUSION: Gestational diabetes insipidus is a rare endocrinopathy complicating pregnancy. This disorder is characterized by excessive thirst, polydypsia, polyuria, hypobaric urine and electrolyte disturbances usually manifesting in the third trimester of pregnancy or puerperium. This is a transient syndrome. The first treatment of choice in patients with gestational diabetes insipidus is 1-deamino-8-D-arginine vasopressin and the second-choice is hydrochlorothiazide. Early diagnosis and appropriate management of the disease may reduce the hazard for both the mother and the fetus during perinatal period.

Pituitary atrial natriuretic peptide of paraventricular nucleus origin.

Atrial natriuretic peptide-synthesizing neurons in the hypothalamic paraventricular nucleus constitute the major sources of ANP in the three lobes of the pituitary gland. Complete transection of the pituitary stalk eliminated 93% of ANP from the intermediate lobe, 47 and 77% from the anterior and the posterior lobes, respectively. Meantime, increased levels of immunoreactive ANP were measured in the median eminence, due to the accumulation of the peptide in the transected axons centrally to the transected stalk and in the paraventricular nucleus. It is likely that ANP neurons in the paraventricular nucleus innervate the pituitary, but those in the periventricular (median) preoptic nucleus and the organum vasculosum laminae terminalis may not contribute to the ANP innervation of the pituitary gland.

Idiopathic hypothalamic diabetes insipidus, pituitary stalk thickening, and the occult intracranial germinoma in children and adolescents.

We report nine consecutive children and adolescents [five females and four males; aged 2 yr 8 months (m) to 18 yr 1 m] studied over the last 5 yr with idiopathic central diabetes insipidus. In addition to vasopressin deficiency, anterior pituitary hormone deficiencies were detected, either on evaluation at presentation or during follow-up studies over the following 3 yr. Four patients had an increased concentration of plasma PRL. One patient had multiple pituitary hormone deficiencies at diagnosis, and two others developed the same by 21 m of follow-up. Brain magnestic resonance imaging scans, performed at presentation, were originally interpreted as normal in four of nine patients, except for absence of the bright posterior pituitary signal; after retrospective review, two of nine were considered normal. All of the brain magnetic resonance imaging (MRI) scans showed positive findings by 14 m of follow-up. The first abnormal finding in all patients was isolated pituitary stalk thickening. Evaluation of cerebrospinal fluid (CSF) for hCG was positive in three of eight evaluated patients; the three positive CSF values were found at presentation and 3 and 9 m after presentation. All eight patients assessed were negative for CSF alpha-fetoprotein and cytology, and no patient had serum tumor markers. Transsphenoidal biopsy of the lesion in seven of nine patients showed a germinoma in six patients and inflammatory cells in one. The six patients with documented germinoma comprise 31% of the intracranial germinomas diagnosed in this age group at the University of California-San Francisco during the last 5 yr. The patient with mononuclear inflammatory cells on biopsy along with one other patient have had spontaneous resolution of their stalk thickening. So-called "idiopathic" central diabetes insipidus warrants close follow-up to determine the etiology, especially if anterior pituitary hormone deficiencies are detected. Normal brain MRI scans or scans that show isolated pituitary stalk thickening merit follow-up with serial contrast enhanced brain MRI for the early detection of an evolving occult hypothalamic-stalk lesion. CSF evaluation is recommended at presentation because elevated CSF hCG may precede MRI abnormalities.

Anterior pituitary function and computed tomography/magnetic resonance imaging in patients with Langerhans cell histiocytosis and diabetes insipidus.

In order to document anterior pituitary dysfunction in patients with biopsy-proven Langerhans cell histiocytosis (LCH) and diabetes insipidus and to correlate this with structural changes on imaging, we performed an insulin tolerance test, enhanced computed tomography (CT), and unenhanced magnetic resonance imaging (MRI) in nine patients. Six of the nine patients had growth hormone deficiency, which in two patients was part of panhypopituitarism and in one was associated with poor cortisol response to insulin hypoglycemia. One patient had an exaggerated growth hormone response and one who had had neck irradiation as an infant, had a high resting thyroid stimulating hormone (TSH) suggesting compensated primary hypothyroidism. All enhanced CTs were abnormal, bony defects being the only abnormality in two patients and opaque mastoids in one. The remaining six patients all had structural changes in the hypothalamic/pituitary region. Unenhanced MRI confirmed the CT findings except in one child who had been treated with radiotherapy in the intervening period, but, in addition, confirmed diabetes insipidus by showing absence of the posterior pituitary bright signal and picked up white matter changes in a child with clinical neurological dysfunction. Our findings indicate that the development of diabetes insipidus in LCH is commonly associated with anterior pituitary dysfunction and is usually associated with structural changes in the hypothalamic/pituitary axis.

Animal models for osmoregulatory disturbances.

For the various types of di in humans, animal models are available. However, their value for explaining human di is for the major part an indirect one; by studying cellular mechanisms in these animal models, fundamental aspects of the cellular processes become available, which will help to understand similar processes in human di and subsequently lead to the molecular cause(s) of the various types of human di. Finally, it is to be expected that in the very near future transgenic animals will be raised in which very specific genetic information is overexpressed (or knocked out by homologous recombination; McMahon and Bradley, 1990). Recently hypervasopressinemia could be shown in transgenic mice, providing an animal model for the syndrome of the inappropriate VP secretion (Bartter and Schwartz, 1967), which is often observed in patients with lung cancers that ectopically express the VP gene (Habener et al., 1989). Furthermore it will be possible to study the exact cause(s) of human di by performing in vitro mutagenesis and to express the RNA constructs within a cell-free translation system and in oocytes (e.g., Schmale et al., 1989) and subsequently study the pattern of precursor synthesis, packaging and processing.

Hereditary diabetes insipidus: an immunohistochemical study of the hypothalamus and pituitary gland.

We report the histological findings in a case of hereditary diabetes insipidus (HDI) using vasopressin (VP) immunohistochemistry. The hypothalamus displayed a marked loss of magnocellular VP neurons, with preservation of the smaller cells. The neurohypophysis was severely atrophic with scanty immunoreactivity. Our results support the hypothesis that HDI results from a selective degeneration of VP neurons affecting chiefly the magnocellular elements projecting to the neurohypophysis. The sparing of the parvocellular component may reflect the projection of these neurons to non-pituitary targets.

Thickened pituitary stalk on MR images in patients with diabetes insipidus and Langerhans cell histiocytosis.

The MR images of four female patients with acute onset of central diabetes insipidus and pathologically confirmed Langerhans cell histiocytosis were evaluated retrospectively for evidence of lesions in the hypothalamic-pituitary axis. The examinations were conducted on a 1.5-T MR system with thin-section sagittal and coronal T1-weighted (short TR/short TE) and T2-weighted (long TR/long TE) images. Three patients underwent T1-weighted MR after IV administration of gadopentetate dimeglumine. Compared with 20 normal subjects who were evaluated with the same MR protocol, three of the four patients had a symmetrically thickened pituitary stalk that demonstrated homogeneous signal enhancement following contrast administration. The high signal intensity of the posterior lobe, which was seen in normal subjects on T1-weighted sagittal images, was absent in all four patients. Two patients had associated abnormalities on either chest films or imaging studies of the temporal bone and two patients had isolated CNS Langerhans cell histiocytosis. The combination of a thickened pituitary stalk and absent posterior pituitary hyperintensity, while nonspecific for Langerhans cell histiocytosis, should nevertheless prompt further studies, such as chest films, bone scanning, or temporal bone CT, to attempt to narrow the differential diagnosis. Gadopentetate dimeglumine, in particular, may be a useful adjunct in the MR examination of the patient with diabetes insipidus.

Fatal central diabetes mellitus and insipidus resulting from untreated hyponatremia: a new syndrome.

After elective hospitalization, eleven healthy young women developed symptomatic hyponatremia that was rapidly followed by polyuria, hypernatremia, hyperglycemia, and death. The patients were 30 +/- 2 years old (+/- SE) with initial serum sodium of 140 +/- 1 mmol/L. They all awoke from analgesia but, 32 hours after completion of the procedure, they went from alertness to respiratory arrest in less than 1 hour. At this time, serum sodium was 116 +/- 2 mmol/L and blood glucose was 6.7 +/- 0.7 mmol/L. Without treatment for the hyponatremia, urine output spontaneously increased from 38 to 689 mL/h and urine osmolality fell from 546 to 83 mmol/kg body weight. Over the next 51 hours, blood glucose rose to a high of 24.1 +/- 2.5 mmol/L while serum sodium rose to a high of 167 +/- 2 mmol/L. None of the patients regained consciousness. At autopsy, all patients had cerebral edema with herniation along with hypoxic brain damage. The pituitary showed infarction of both anterior and posterior lobes in 7 of 7 patients examined, while 8 of 11 had necrosis of the medulla and 8 of 8 patients examined had hypothalamic necrosis. All had normal pancreas and kidneys at autopsy. Soon after respiratory arrest, all of the patients developed fixed, dilated pupils that often led to the diagnosis of brain death. Autopsy showed compression of the third cranial nerve (oculomotor) because of cerebral herniation. Thus, all of the patients were diagnosed as being brain dead when some may have been saved. These data suggest that in otherwise healthy young women, untreated symptomatic hyponatremia may lead to brain edema, cerebral herniation, and infarction of pituitary and hypothalamus, resulting in central diabetes insipidus and mellitus.

The neuroanatomical and neurovascular organization of normal fetal hypothalamic explants in the third cerebral ventricle of Brattleboro rats with homozygous diabetes insipidus.

This investigation has combined microangiography, immunocytochemistry, coupled with transmission and scanning electron microscopy to discuss the neuroanatomical interactions that occur in the brains of Brattleboro rats with diabetes insipidus, following stereotaxic placement of normal fetal hypothalamic fragments into the third cerebral ventricle. Following surgical placement of 17 day post-coitus hypothalamic fragments, host rats with chronic autosomal homozygous diabetes insipidus were killed and their brains were prepared for analysis. A significant degree of explants (68%) flourished and grew in the lumen of the third cerebral ventricle of recipient hosts. Explants were rapidly invaded by host vessels from two routes. Vessels arose from the underlying mantle plexus of portal capillaries which remained fenestrated in the lower one-third of the explants and developed neurovascular (neurohemal) zones. The second source of vessels arose from bed capillaries of the adjacent paraventricular nucleus and adjacent hypothalamus. In contrast to vessels arising from the contact zone, these latter vessels remained unfenestrated. Small clusters of immunocytochemically positive neurons (neurophysin positive) were seen throughout the explants. Numerous healthy magnocellular neurons harboring numerous dense core vesicles and exhibiting multiple axosomatic and axodendritic synapses were seen throughout the neuropil of explants. Axon profiles were noted to terminate upon the abluminal basal lamina of perivascular spaces surrounding fenestrated capillaries in the lower one third of explants. None of the host animals exhibited physiological return to normal parameters of urine output, drinking behavior, and/or urine osmolarity. However the growth and development of explants in the third cerebral ventricle of DI hosts coupled with the emergence of bonafide neurovascular zones supports a potential anatomical substrate for the central delivery of neuropeptide hormones in this experimental model.

Immunohistochemical localization of human pituitary glycopeptide (HPGP)-like immunoreactivity in the hypothalamus and pituitary of normal and homozygous diabetes insipidus (Brattleboro) rats.

Sections of the hypothalami and pituitary glands of normal (Sprague-Dawley) and homozygous diabetes insipidus (Brattleboro) rats were stained with antiserum to a human pituitary glycopeptide (HPGP) by using the immunohistochemical peroxidase-antiperoxidase method at the light microscopic level. Our results show in normal rats that immunoreactive HPGP was localized in the perikarya of the magnocellular neurons of the hypothalamus, in the posterior pituitary, and in the nerve fibers distributed in the median eminence (ME) and in the areas between the supraoptic nuclei (SON), paraventricular nuclei (PVN), and median eminence and also in the suprachiasmatic nuclei (SCN), a part of the parvocellular system. In the Brattleboro rats, however, no staining was found either in the hypothalami or pituitary glands. The present data strongly support our previous hypothesis that HPGP, a 39 residue glycopeptide isolated from human neurohypophysis, may be part of the precursor of arginine-vasopressin and its neurophysin II (Pro-NP-AVP).

ADH-dependent nephron heterogeneity in rats with hereditary hypothalamic diabetes insipidus.

Single nephron glomerular filtration rates (SNGFR) were measured by the [14C]sodium ferrocyanide infusion technique in superficial (S) and juxtamedullary nephrons (JM) of anesthetized Brattleboro rats with or without diabetes insipidus (DI and HZ, respectively). Glomerular volumes (GV) and proximal tubular lengths (PTL) were measured in the same nephrons after microdissection. Glomerular volumes were also assessed in Wistar, HZ, and DI rats in Microfil-injected kidneys. The well-known nephron heterogeneity of the mammalian kidney was absent or greatly reduced in DI compared to HZ rats. S/JM ratios for SNGFR, GV, and PTL averaged 0.71, 0.50, and 0.73 in HZ and 1.04, 0.77, and 0.90 in DI rats. This reduced nephron heterogeneity was due only to reduced dimensions and filtration rates in JM nephrons. The chronic administration of antidiuretic hormone (dDAVP or vasopressin tannate), begun at 2 wk of age and maintained until adulthood (8-10 wk), significantly decreased the S/JM ratios, i.e., restored a nearly normal nephron heterogeneity in DI rats. These results suggest that nephron heterogeneity in the rat kidney is dependent on the presence of antidiuretic hormone, and, more specifically, that ADH and/or its functional consequences can selectively induce an increase in size and filtration rate in deep nephrons.