Syndrome of inappropriate antidiuretic hormone differential diagnosis: Difference between revisions

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{{Syndrome of inappropriate antidiuretic hormone}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Syndrome_of_inappropriate_antidiuretic_hormone]]
{{CMG}}; {{AE}} {{Vbe}}
{{CMG}}; {{AE}}{{Vbe}}


==Overview==  
==Overview==  
[[SIADH]] consists of[[ hyponatremia]], inappropriately elevated urine[[ 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|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 IND|treatment]] plan.
Syndrome of inappropriate antidiuretic hormone (SIADH) must be differentiated from other causes of [[hyponatremia]], such as [[cerebral salt wasting syndrome]], [[adrenal insufficiency]], [[hypopituitarism]], and [[psychogenic polydipsia]].
 
==Differentiating Syndrome of Inappropriate Antidiuretic Hormone from other Diseases==
==Differentiating Syndrome of inappropriate antidiuretic hormone from other Diseases==
[[SIADH]] must be differentiated from cerebral salt wasting, [[ adrenal insufficiency]], [[hypopituitarism]], [[hypothyroidism]], and [[psychogenic polydipsia]].<ref name="pmid27936532">{{cite journal |vauthors=Heidelbaugh JJ |title=Endocrinology Update: Hypopituitarism |journal=FP Essent |volume=451 |issue= |pages=25–30 |year=2016 |pmid=27936532 |doi= |url=}}</ref><ref name="pmid15241506">{{cite journal |vauthors=Hammer F, Arlt W |title=[Hypopituitarism] |language=German |journal=Internist (Berl) |volume=45 |issue=7 |pages=795–811; quiz 812–3 |year=2004 |pmid=15241506 |doi=10.1007/s00108-004-1216-5 |url=}}</ref><ref name="pmid25712898">{{cite journal |vauthors=de Fost M, Oussaada SM, Endert E, Linthorst GE, Serlie MJ, Soeters MR, DeVries JH, Bisschop PH, Fliers E |title=The water deprivation test and a potential role for the arginine vasopressin precursor copeptin to differentiate diabetes insipidus from primary polydipsia |journal=Endocr Connect |volume=4 |issue=2 |pages=86–91 |year=2015 |pmid=25712898 |pmc=4401105 |doi=10.1530/EC-14-0113 |url=}}</ref>
[[SIADH]] must be differentiated from cerebral salt wasting, [[ adrenal insufficiency]], [[hypopituitarism]], [[hypothyroidism]], and [[psychogenic polydipsia]]<ref name="pmid27936532">{{cite journal |vauthors=Heidelbaugh JJ |title=Endocrinology Update: Hypopituitarism |journal=FP Essent |volume=451 |issue= |pages=25–30 |year=2016 |pmid=27936532 |doi= |url=}}</ref><ref name="pmid15241506">{{cite journal |vauthors=Hammer F, Arlt W |title=[Hypopituitarism] |language=German |journal=Internist (Berl) |volume=45 |issue=7 |pages=795–811; quiz 812–3 |year=2004 |pmid=15241506 |doi=10.1007/s00108-004-1216-5 |url=}}</ref><ref name="pmid25712898">{{cite journal |vauthors=de Fost M, Oussaada SM, Endert E, Linthorst GE, Serlie MJ, Soeters MR, DeVries JH, Bisschop PH, Fliers E |title=The water deprivation test and a potential role for the arginine vasopressin precursor copeptin to differentiate diabetes insipidus from primary polydipsia |journal=Endocr Connect |volume=4 |issue=2 |pages=86–91 |year=2015 |pmid=25712898 |pmc=4401105 |doi=10.1530/EC-14-0113 |url=}}</ref>
{| class="wikitable"
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Disease
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Causes
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Symptoms
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Diagnosis and treatment
|- Diagnostic criteria of SIADH include:
 
|[[SIADH]]
|[[SIADH]] is a syndrome characterized by excessive release of [[Vasopressin|antidiuretic hormone]] (ADH or vasopressin) from the [[posterior pituitary]] gland or another source. The result is [[hyponatremia]], and sometimes [[fluid]] overload
|
*[[Nausea]] / [[vomiting]]
*[[Cramps]]
*[[Depressed mood]]
*[[Irritability]]
*[[Confusion]]
*[[ Hallucinations]]
*[[Seizures]], [[stupor]] or [[coma ]]
|
*[[Hyponatremia ]] <135 mmol/l
 
*Effective serum [[osmolality]]<275mosm
 
*Urine [[sodium]] concentration>40mmol/litre
 
*Plasma [[uric acid]] <200;FeUrate>12%
 
*Absence of [[Edematous malnutrition|edematous]] disease like[[ cardiac failure]], [[liver cirrhosis]],[[ nephrotic syndrome]].


{| style="border: 0px; font-size: 90%; margin: 3px; width: 1000px" align="center"
| valign="top" |
|+
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Differential Diagnosis}}
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Similar Features}}
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Differentiating Features}}
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[SIADH]]
| style="padding: 5px 5px; background: #F5F5F5;" |
*Excessive release of [[Vasopressin|antidiuretic hormone (ADH or vasopressin)]]  from the [[posterior pituitary]] gland or another source.
*[[Hyponatremia]]
*[[Fluid]] overload
*[[Hyponatremia]] <135 mmol/l
*Effective serum [[osmolality]] < 275 mOsm
*Urine [[sodium]] concentration > 40 mMol/l
*Plasma [[uric acid]] < 200
*Absence of [[edema]]-inducing diseases, such as [[heart failure]], [[liver cirrhosis]], and [[nephrotic syndrome]]
*Normal [[adrenal]] and [[thyroid]] function
*Normal [[adrenal]] and [[thyroid]] function
 
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Weight loss]] (in case of [[malignancy]])
* History of head [[trauma]]
* History of medication intake
* Positive [[family history]]
|-
|-
|[[Cerebral salt wasting syndrome]]
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[Cerebral salt wasting syndrome]]
 
| style="padding: 5px 5px; background: #F5F5F5;" |
|[[ Cerebral salt wasting syndrome]] is defined as the[[ renal]] loss of [[sodium]] during [[Intracranial Bleeding|intracranial]] [[disease]] leading to [[hyponatremia]] and a decrease in extracellular [[fluid]] volume
*[[Hyponatremia]]
 
*Urine [[sodium]] concentration > 40 mMol/l
*[[Trauma]]
*[[Tumor]]
*[[Hematoma]]
 
|The patient is
*[[Hypovolemic]]
*[[Hyponatremia|Hyponatremic]]


|Treatment is
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Hydration]] and
*[[Hypovolemia]]
*[[Sodium]] replacement
*Intracranial [[diseases]], such as:
**[[Tumor]]
**[[Trauma]]
**[[Hematoma]]
|-
|-
|[[Adrenal insufficiency]]
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[Adrenal insufficiency]]
 
| style="padding: 5px 5px; background: #F5F5F5;" |
|[[Adrenal insufficiency]]  
*[[Hyponatremia]]
* [[ Mineralocorticoid deficiency]] is present. [[Secondary]] or [[tertiary adrenal insufficiency]] will  have preserved[[ mineralocorticoid]] function owing to  separate feedback mechanisms
Adrenal insufficiency can be
*[[Primary]]
*[[Secondary]]
[[Tertiary]]
Common causes of primary adrenal insufficiency:
*[[Autoimmune]]
*[[Iatrogenic]]
*[[Drugs]]
* [[Adrenal hemorrhage]]
*[[Cancer]]
*[[Infection]]
*[[Congenital]]
*Secondary [[Adrenal gland|adrenal]] insufficiency: ( [[Aldosterone]]) levels normal
*Most common causes are:
*[[Traumatic brain injury (TBI) ]]
*[[Panhypopituitarism]] 
*Tertiary [[Adrenal gland|adrenal]] insufficiency
*Exogenous[[ steroid]] 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
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Weight loss]]
*[[Weight loss]]
*Sparse [[axillary]] hair
*Sparse [[axillary]] hair
*[[Hyperpigmentation]]  
*[[Hyperpigmentation]]  
*[[Orthostatic hypotension]].
*[[Orthostatic hypotension]]
 
Acute [[addisonian]] crisis is characterized by:
*[[Fever]]  
*[[Fever]]  
*[[ Hypotension]]
*[[Hypotension]]
|The diagnosis of [[Addisons]] disease is made through rapid [[ACTH]] administration and measurement of [[cortisol]].
*[[Eosinophilia]]
*Lab findings include:
*[[White blood cell]] count with moderate [[neutropenia]]
*[[Lymphocytosis]]
*[[ Eosinophilia]]
*[[Hyperkalemia]]  
*[[Hyperkalemia]]  
* [[Hypoglycemia]]
*[[Hypoglycemia]]
*Morning low plasma [[cortisol]]
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[Hypopituitarism]]
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Hyponatremia]]
*[[Hyponatremia]]
* Morning low plasma [[cortisol]].
| style="padding: 5px 5px; background: #F5F5F5;" |
The definitive diagnosis is the [[cosyntropin]] or [[ACTH]] stimulation test. A[[ cortisol]] 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,measure [[cortisol]] level,then rapidly administer
*[[ Fluids]]
*[[ Hydrocortisone]] 
|-
|[[Hypopituitarism]]
| Abnormality in [[anterior pituitary]] function
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]]
* [[Fatigue]]
* [[Weight loss]]
* [[Weight loss]]
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* [[Anemia]]
* [[Anemia]]
* [[Infertility]]
* [[Infertility]]
*[[ Cold insensitivity]].
* [[Cold intolerance]]
* [[Amenorrha]]
* [[Amenorrhea]]
*[[Inability to lactate]] in [[breast feeding]] women
* Inability to lactate in [[breast feeding]] women
* Decreased [[facial]] or[[ body hair]] in men
* Decreased [[facial]] or [[body hair]] in men
* [[Short stature]] in children
* [[Short stature]] in children
|
* [[History]] and[[ physical examination]], including [[visual field]] testing, are important.
The treatment of permanent hypopituitarism consists of replacement of the peripheral hormones
*[[Hydrocortisone]]
*[[DHEA]]
*[[Thyroxine]]
*[[Testosterone]] or [[oestradiol]]
*[[ Growth hormone]]
*[[Surgery]] and/or
*[[ Radiotherapy]] to restore normal [[endocrine]] function and quality of life
*Life long [[Monitoring competence|monitoring]] of serum [[hormone]] levels and [[symptoms]] of hormone deficiency or excess is needed in these [[patients]]
|-
|-
|[[Hypothyroidism]]
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[Psychogenic polydipsia]]  
|Hypofunctioning of the thyroid gland due to multifactorial etiology ranging from congenital to [[autoimmune]] causes described below:
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Congenital]]
*[[Fluid]] overload
*[[Autoimmune]]
*[[Hyponatremia]]
*[[Drugs]]
| style="padding: 5px 5px; background: #F5F5F5;" |
*Post [[surgery]]
*Defect in the [[hypothalamus]]
*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.
*The drug of choice for treatment is [[Levothyroxine]]
|-
|[[Psychogenic polydipsia]]
| Also called as[[ primary polydipsia]] is characterized by[[ polyuria]] and [[polydipsia]]. Causes are:
* Defect in the [[hypothalamus]]
*Adverse effect of a [[medication]]
*Traumatic[[ brain]] injury
*[[Psychiatric]] disorders such as [[schizophrenia]]
|
*[[Polyuria]]
*[[Polyuria]]
*[[Polydipsia]]
*[[Polydipsia]]
Line 200: Line 88:
*[[Lethargy]]
*[[Lethargy]]
*[[Psychosis]]
*[[Psychosis]]
*[[Seizures]] and
*[[Seizures]]  
*Sometimes, even death
|Evaluation of[[ psychiatric]] patients with polydipsia requires an evaluation for other medical causes of polydipsia, polyuria,[[ hyponatremia]], and the syndrome of inappropriate secretion of antidiuretic hormone.
*The management strategy in[[ psychiatric]] patients should include:
 
*[[Fluid]] restriction and[[ behavioral]] and [[pharmacologic]] modalities.
*The [[water deprivation test]] is the [[gold standard]] test
|}
|}
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


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Latest revision as of 00:22, 30 July 2020

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

Overview

Syndrome of inappropriate antidiuretic hormone (SIADH) must be differentiated from other causes of hyponatremia, such as cerebral salt wasting syndrome, adrenal insufficiency, hypopituitarism, and psychogenic polydipsia.

Differentiating Syndrome of Inappropriate Antidiuretic Hormone from other Diseases

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

Differential Diagnosis Similar Features Differentiating Features
SIADH
Cerebral salt wasting syndrome
Adrenal insufficiency
Hypopituitarism
Psychogenic polydipsia

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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