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Central adrenal insufficiency and diabetes insipidus misdiagnosed as severe depression.

Hiroi N, Yoshihara A, Sue M, Yoshino G, Higa M - Clin Med Insights Case Rep (2010)

Bottom Line: Plasma ACTH did not increase with insulin loading.Six months after starting administration of hydrocortisone and 1-deamino-8D-arginine vasopressin, his psychological symptoms had improved, and 1.5 years after starting treatment, he was able to walk.In conclusion, it is not particularly rare for adrenal insufficiency to be misdiagnosed as depression.

View Article: PubMed Central - PubMed

Affiliation: Department of Diabetes and Endocrinology, Saiseikai Yokohamashi-Tobu Hospital, Yokohama, Kanagawa, Japan.

ABSTRACT
A 68 year-old Japanese man, who had been suffering from immobilization and disuse syndrome, was admitted to our hospital for evaluation of polyuria with polyposia, hyponatremia and low blood pressure. His plasma osmolality was greater than that of his urine. His endocrinological examination revealed low levels of plasma adrenocorticotropic hormone (ACTH) and cortisol, and a normal response of ACTH to the corticotrophin-releasing hormone (CRH) challenge. Plasma ACTH did not increase with insulin loading. A low plasma vasopressin (AVP) level and no response of AVP to a 5% saline administration were observed. We diagnosed central adrenal insufficiency with central diabetes insipidus. Six months after starting administration of hydrocortisone and 1-deamino-8D-arginine vasopressin, his psychological symptoms had improved, and 1.5 years after starting treatment, he was able to walk. In conclusion, it is not particularly rare for adrenal insufficiency to be misdiagnosed as depression. However, a correct early diagnosis is necessary, because, if adrenal insufficiency is not definitively diagnosed, the patient's quality of life diminishes markedly.

No MeSH data available.


Related in: MedlinePlus

Response of AVP to 5% saline loading test. There was no response of AVP to a 5% saline loading test in our patient (closed circle). The gray area represents the normal response of AVP to 5% saline administration.
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f1-ccrep-2010-055: Response of AVP to 5% saline loading test. There was no response of AVP to a 5% saline loading test in our patient (closed circle). The gray area represents the normal response of AVP to 5% saline administration.

Mentions: On physical examination, a depressive effect, hypotension and arthrogryposis were observed. His urinary volume was approximately 3000 mL/day. Hematological data showed mild anemia and bio-chemical analysis detected hyponatremia (133 mM) on admission. Serum levels of aspartate aminotransferase, urea nitrogen, creatinine and C-reactive peptide were elevated (40 IU/L, 38.7 mg/dL, 1.52 mg/dL and 0.8 mg/dL, respectively). His plasma osmolality (pOsm) was greater than that of his urine (uOsm) (355 mOsm/kg and 288 mOsm/kg, respectively). Endocrinological examinations showed plasma adrenocorticotropic hormone (ACTH) and cortisol levels of 23.5 pg/mL (normal range: 7.4–55.7 pg/mL) and 3.6 μg/dL (normal range: 4.0–18.3 μg/dL), respectively, at 7:30 a.m. with loss of circadian rhythm. Mean 24 hour urinary 17-hydroxycorticosteroid and 17-ketosterol levels were below normal at 1.5 mg/day (normal range: 4–12 mg/day) and 2.2 mg/day (normal range: 5–20 mg/day), respectively. The responses of plasma ACTH and cortisol to intravenous injection of CRH were normal. Plasma ACTH and cortisol levels did not increase in response to intravenous injection of insulin. The cortisol response to a single administration of 1–24 ACTH was normal. Levels of free triiodothyronine and free thyroxin were normal, and thyroid-stimulating hormone (TSH) showed a normal response to thyrotropin-releasing hormone injection. Levels of plasma prolactin, growth hormone and insulin like growth factor-1 were 9.8 ng/mL (normal range: 3.58–12.78 ng/mL), 0.1 ng/mL (normal range: <0.17 ng/mL) and 159 ng/mL (normal range: 42–250 ng/mL), respectively. The plasma vasopressin (AVP) level was relatively low, at 0.4 pg/mL (normal range: 0.3–3.5 ng/mL). AVP showed no response to a 5% saline loading test. T1-weighted magnetic resonance imaging of the pituitary gland showed an empty sella and disappearance of high intensity at the posterior lobe (Fig. 1).


Central adrenal insufficiency and diabetes insipidus misdiagnosed as severe depression.

Hiroi N, Yoshihara A, Sue M, Yoshino G, Higa M - Clin Med Insights Case Rep (2010)

Response of AVP to 5% saline loading test. There was no response of AVP to a 5% saline loading test in our patient (closed circle). The gray area represents the normal response of AVP to 5% saline administration.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3046013&req=5

f1-ccrep-2010-055: Response of AVP to 5% saline loading test. There was no response of AVP to a 5% saline loading test in our patient (closed circle). The gray area represents the normal response of AVP to 5% saline administration.
Mentions: On physical examination, a depressive effect, hypotension and arthrogryposis were observed. His urinary volume was approximately 3000 mL/day. Hematological data showed mild anemia and bio-chemical analysis detected hyponatremia (133 mM) on admission. Serum levels of aspartate aminotransferase, urea nitrogen, creatinine and C-reactive peptide were elevated (40 IU/L, 38.7 mg/dL, 1.52 mg/dL and 0.8 mg/dL, respectively). His plasma osmolality (pOsm) was greater than that of his urine (uOsm) (355 mOsm/kg and 288 mOsm/kg, respectively). Endocrinological examinations showed plasma adrenocorticotropic hormone (ACTH) and cortisol levels of 23.5 pg/mL (normal range: 7.4–55.7 pg/mL) and 3.6 μg/dL (normal range: 4.0–18.3 μg/dL), respectively, at 7:30 a.m. with loss of circadian rhythm. Mean 24 hour urinary 17-hydroxycorticosteroid and 17-ketosterol levels were below normal at 1.5 mg/day (normal range: 4–12 mg/day) and 2.2 mg/day (normal range: 5–20 mg/day), respectively. The responses of plasma ACTH and cortisol to intravenous injection of CRH were normal. Plasma ACTH and cortisol levels did not increase in response to intravenous injection of insulin. The cortisol response to a single administration of 1–24 ACTH was normal. Levels of free triiodothyronine and free thyroxin were normal, and thyroid-stimulating hormone (TSH) showed a normal response to thyrotropin-releasing hormone injection. Levels of plasma prolactin, growth hormone and insulin like growth factor-1 were 9.8 ng/mL (normal range: 3.58–12.78 ng/mL), 0.1 ng/mL (normal range: <0.17 ng/mL) and 159 ng/mL (normal range: 42–250 ng/mL), respectively. The plasma vasopressin (AVP) level was relatively low, at 0.4 pg/mL (normal range: 0.3–3.5 ng/mL). AVP showed no response to a 5% saline loading test. T1-weighted magnetic resonance imaging of the pituitary gland showed an empty sella and disappearance of high intensity at the posterior lobe (Fig. 1).

Bottom Line: Plasma ACTH did not increase with insulin loading.Six months after starting administration of hydrocortisone and 1-deamino-8D-arginine vasopressin, his psychological symptoms had improved, and 1.5 years after starting treatment, he was able to walk.In conclusion, it is not particularly rare for adrenal insufficiency to be misdiagnosed as depression.

View Article: PubMed Central - PubMed

Affiliation: Department of Diabetes and Endocrinology, Saiseikai Yokohamashi-Tobu Hospital, Yokohama, Kanagawa, Japan.

ABSTRACT
A 68 year-old Japanese man, who had been suffering from immobilization and disuse syndrome, was admitted to our hospital for evaluation of polyuria with polyposia, hyponatremia and low blood pressure. His plasma osmolality was greater than that of his urine. His endocrinological examination revealed low levels of plasma adrenocorticotropic hormone (ACTH) and cortisol, and a normal response of ACTH to the corticotrophin-releasing hormone (CRH) challenge. Plasma ACTH did not increase with insulin loading. A low plasma vasopressin (AVP) level and no response of AVP to a 5% saline administration were observed. We diagnosed central adrenal insufficiency with central diabetes insipidus. Six months after starting administration of hydrocortisone and 1-deamino-8D-arginine vasopressin, his psychological symptoms had improved, and 1.5 years after starting treatment, he was able to walk. In conclusion, it is not particularly rare for adrenal insufficiency to be misdiagnosed as depression. However, a correct early diagnosis is necessary, because, if adrenal insufficiency is not definitively diagnosed, the patient's quality of life diminishes markedly.

No MeSH data available.


Related in: MedlinePlus