Multiple Endocrinopathies Associated with Lithium Therapy

ObjectiveTo illustrate a case of lithium-associated primary hyperparathyroidism, thyrotoxicosis, and nephrogenic diabetes insipidus and to discuss the potential mechanisms for these complications.MethodsWe describe the clinical and laboratory findings in our current patient and review the related medical literature.ResultsA 65-year-old Chinese woman with bipolar affective disorder, who had received maintenance lithium therapy for 10 years, was seen in an acute care hospital because of fever and confusion. Investigations showed that she had primary hyperparathyroidism and hyperthyroidism. She underwent a parathyroidectomy, which revealed a parathyroid adenoma. Her initial subclinical hyperthyroidism evolved into overt hyperthyroidism after use of lithium was discontinued. Therapy was initiated with carbimazole, which was up-titrated briefly; the patient was subsequently weaned off this medication. Her postoperative course was complicated by persistent polyuria in conjunction with a negative fluid balance, consistent with nephrogenic diabetes insipidus. Thus, amiloride therapy was instituted. The results of an objective causality assessment suggested that the primary hyperparathyroidism, hyperthyroidism, and nephrogenic diabetes insipidus were possibly or probably related to the lithium therapy.ConclusionLithium remains an intriguing drug with numerous potential endocrinologic complications. It is important that clinicians prescribing lithium are aware of its side effects and have a strategy for their detection and management. (Endocr Pract. 2007;13:758-763)     

Sheehan Syndrome Presenting as Central Diabetes Insipidus: A Rare Presentation of an Uncommon Disorder

ObjectiveTo add to the current scant literature on rare clinical presentations of Sheehan syndrome.MethodsWe describe the study patient’s clinical, laboratory, and imaging findings and review the literature for publications regarding varied clinical presentations of Sheehan syndrome.ResultsA 36-year-old multigravida woman developed severe postpartum hemorrhage and disseminated intravascular coagulation followed by Sheehan syndrome, with central diabetes insipidus as the primary presenting feature. This was diagnosed when, postoperatively, she developed polyuria with a urine output of 11 L in 24 hours with an accompanying rise in creatinine. She had laboratory evidence of diabetes insipidus, with serum osmolality greater than urine osmolality. Her clinical status improved significantly with intranasal desmopressin supplementation, thus confirming the diagnosis of Sheehan syndrome. Although Sheehan syndrome is a known complication of postpartum hemorrhage, central diabetes insipidus is seldom considered or suspected. Hypovolemia is usually presumed to be secondary to blood loss and polyuria resulting from a diuretic phase of acute renal failure.ConclusionsIt is important to consider posterior pituitary ischemia resulting from Sheehan syndrome presenting as central diabetes insipidus as a cause of polyuria because appropriate hormonal replacement initiated early can possibly improve clinical status and patient outcomes. (Endocr Pract. 2011;17:108-114)     

Diabetes insipidus and exogenous antidiuretic hormone activity modifications by lithium in the rat]

The authors made conspicuous in the rat the appearance of "diabetes insipidus" induced by two lithium salts: chloride and carbonate administered orally, with increasing doses in food. The polyuria, polydipsia and urinary hypotony are reversible and disappeared with stopping the treatment. The animals became insensible to the exogenous antidiuretic hormon during the treatment and progressively became sensible again during the following twenty days so suggesting a nephrogenic mechanism by lithium: either a loss of ADH activity, either the abolition of intrarenal osmotic pressure gradient.     

A complicated pregnancy in a patient with lipodystrophic diabetes attributable to a peroxisome proliferator-activated receptor gamma (PPARG) mutation

Diabet. Med. 29, e398-e401 (2012) ABSTRACT: Background We describe an unplanned pregnancy in a 19-year-old with lipodystrophic diabetes caused by a mutation in the peroxisome proliferator-activated receptor gamma (PPARG) gene. The pregnancy was complicated by poor compliance with treatment, severe hypertriglyceridaemia and pancreatitis. Case report The patient presented at 6?weeks' gestation with an HbA(1c) of 140?mmol/mol (15%), cholesterol 8.1?mmol/l and triglycerides 20.1?mmol/l. She wished to continue the pregnancy so lipid-lowering therapy was discontinued. She was severely insulin resistant and poorly compliant with diet and medication. A continuous subcutaneous insulin infusion was required for efficient delivery of large doses of basal insulin, alongside injected mealtime boluses, (up to 300?units insulin per day). At 17?weeks' gestation she developed acute pancreatitis secondary to hypertriglyceridaemia (triglycerides >?100?mmol/l) and required plasmapheresis. Lipid-lowering therapy was reinstated in the third trimester and plasmapheresis was required repeatedly to maintain triglycerides 相似文献   

Diabetes insipidus in mice with a mutation in aquaporin-2

Congenital nephrogenic diabetes insipidus (NDI) is a disease characterized by failure of the kidney to concentrate urine in response to vasopressin. Human kindreds with nephrogenic diabetes insipidus have been found to harbor mutations in the vasopressin receptor 2 (Avpr2) gene or the vasopressin-sensitive water channel aquaporin-2 (Aqp2) gene. Development of a treatment is rendered difficult due to the lack of a viable animal model. Through forward genetic screening of ethylnitrosourea-mutagenized mice, we report the identification and characterization of a mouse model of NDI, with an F204V mutation in the Aqp2 gene. Unlike previously attempted murine models of NDI, our mice survive to adulthood and more exactly recapitulate the human disorder. Previous in vitro experiments using renal cell lines suggest recessive Aqp2 mutations result in improper trafficking of the mutant water pore. Using these animals, we have directly proven this hypothesis of improper AQP2 translocation as the molecular defect in nephrogenic diabetes insipidus in the intact organism. Additionally, using a renal cell line we show that the mutated protein, AQP2-F204V, is retained in the endoplasmic reticulum and that this abnormal localization can be rescued by wild-type protein. This novel mouse model allows for further mechanistic studies as well as testing of pharmacological and gene therapies for NDI.     

Diabetes Insipidus in Pregnancy: Etiology,Evaluation, and Management

ObjectiveTo review the approach to a patient with diabetes insipidus during pregnancy.MethodsThis review examines the normal physiology of water homeostasis, the related changes that occur during pregnancy, and the pathophysiology of diabetes insipidus in pregnancy. Associated complications, evaluation, and management are discussed.ResultsDiabetes insipidus can complicate up to 1 in 30000 pregnancies. Diabetes insipidus during pregnancy has a variety of causes, some that predate the pregnancy and others that begin during gestation. Polyuria and polydipsia can occur or be exacerbated in women with overt or subclinical central or nephrogenic diabetes insipidus. These women have either decreased central secretory reserve or impaired renal responsiveness to vasopressin. In addition, women can experience diabetes insipidus de novo in pregnancy through the actions of placental vasopressinase, which causes accelerated degradation of vasopressin. This form of diabetes insipidus may be associated with increased complications of pregnancy, including preeclampsia. Management of central diabetes insipidus and transient diabetes insipidus of pregnancy can be achieved with 1-deamino-8-D-arginine vasopressin (desmopressin acetate) (DDAVP), a vasopressin analogue. Nephrogenic diabetes insipidus is typically resistant to both DDAVP and vasopressin and underlying causes should be addressed.ConclusionsIncreased awareness of diabetes insipidus in pregnancy may lead to early diagnosis and appropriate treatment that will reduce the risks of maternal and fetal morbidity. Overall, growing experience with DDAVP has shown that it is a safe and effective treatment for diabetes insipidus caused by a variety of factors. (Endocr Pract. 2009;15:377-382)     

Liver and mammary arylhydrocarbon hydroxylase and epoxide hydratase in lactating rats fed polybrominated biphenyls

Female rats were fed polybrominated biphenyls (PBBs) (50 ppm) from day 8 of gestation through day 14 postpartum. Hepatic and mammary liver to body weight ratios, microsomal protein, arylhydrocarbon (benzo(a)pyrene) hydroxylase (AHH) activity and epoxide hydratase (EH) activities were measured. Exposure to PBBs significantly increased liver to body weight ratio, hepatic microsomal protein and hepatic AHH and EH activities. Mammary AHH activity was increased and EH activity was decreased after PBBs. These data demonstrate that AHH and EH are present in mammary tissue and can be altered by exposure to PBBs.     

PPAR-gamma,TNF-alpha messenger RNA levels and lipase activity in the pregnant and lactating rat

Dramatic alternations in maternal metabolism occur during gestation and lactation, especially glucose and fat metabolism. For example, in rats, the amount of body fat mass increases during gestation, then decreases just prior to delivery, and remains low after parturition. To investigate the factors involved in such changes in maternal fat mass, messenger ribonucleic acid (mRNA) levels of adipocytokines, peroxisome proliferator-activated receptor-gamma (PPAR-gamma) and tumor necrosis factor-alpha (TNF-alpha), were examined in the intraabdominal adipose tissue of non-pregnant rats, pregnant rats and postpartum rats. We also examined the issue of whether apoptosis, which could be promoted by PPAR-gamma and TNF-alpha, is involved in any of the changes in maternal fat mass The activity of lipoprotein lipase (LPL) and hormone sensitive lipase (HSL) in adipose tissue was also measured. PPAR-gamma and TNF-alpha mRNA levels remained constant during the gestational and postpartum periods. Apoptosis was not detected at any time as evidenced by DNA laddering and in situ staining. LPL activity was significantly increased at day 5 and remained elevated until day 14 of gestation. HSL activity was significantly increased at day 10 of gestation and then decreased after delivery, at day 10 of lactation. In conclusion, during the gestational and postpartum period of rats, changes in maternal fat mass did not directly correlate with the levels of expression of PPAR-gamma and TNF-alpha mRNA. Apoptosis also does not appear to influence on fat mass change. The changes in LPL and HSL activities during gestation suggest that these enzymes might be regulators of maternal adipose tissue level.     

Determination of apolipoprotein A-I synthesis in intestinal explants from fetal and neonatal rats

The ability of rat intestine and liver to synthesize the main constitutive apoproteins of HDL (apolipoproteins (apo) A-I, A-IV and E) was studied by incorporation of [3H]leucine in vitro at different stages of perinatal life. In both organs, apoprotein synthesis was barely detectable at day 18 of gestation; it was initiated 2 days before the end of gestation. Apo A-I synthesis leveled off at birth in the intestine but kept increasing in the liver during suckling. Intestinal apo A-IV and hepatic apo E synthesis became stable 5 days after birth. Hormonal determination of apo A-I synthesis was examined at different ages in jejunum cultured for 48 h in vitro in the presence of effectors. The addition of dexamethasone to the culture medium was without effect on intestine explanted either at day 18 of gestation or at different postnatal ages (0, 2 and 5 days), but induced the specific stimulation of apo A-I synthesis at day 20 of gestation. At this stage, triiodothyronine alone was ineffective, whereas it enhanced the dexamethasone-induced stimulation. Apo A-I synthesis remained unaffected by insulin alone or combined with the glucocorticoid. Administration of cortisone acetate to pregnant rats from day 14 of gestation onwards resulted in a stimulation of apo A-I synthesis only when it was prolonged after the 20th day of gestation. No effect of dietary substrates could be obtained in vitro. It is concluded that glucocorticoids specifically potentiate prenatal apo A-I synthesis in the rat intestine but that their action is limited to the days immediately preceding birth. They cannot induce early maturation nor stimulate existing synthesis.     

The ovary of the gestating South American plains vizcacha (Lagostomus maximus): suppressed apoptosis and corpora lutea persistence

The South American plains vizcacha, Lagostomus maximus, displays an exceptional ovulation rate of up to 800 eggs per cycle, the highest rate recorded for a mammal. Massive polyovulation arises from the overexpression of the apoptosis-inhibiting BCL2 gene leading to a suppression of apoptotic pathways responsible for follicular atresia in mammals. We analyzed the ovarian histology, ovarian apoptosis, and apoptosis-related protein expression with special emphasis in corpora lutea throughout the 5-mo-long gestation period, at parturition day and early postpartum, in L. maximus. Corpora lutea were abundant throughout gestation with no sign of structural regression even at the end of gestation. Both immunohistochemistry and Western blot analysis showed strong signals for apoptosis-inhibiting BCL2 protein, whereas the proapoptotic BAX protein was just detected in isolated luteal cells in gestating females and postpartum females. Apoptosis-associated DNA fragmentation detected by TUNEL was very scarce and occasional and correlated with BAX detection in luteal cells. Marked expression of progesterone and alpha-estrogen receptors in luteal cells was found at early, mid-, and late gestation as well as at parturition day and early postpartum samples. Additionally, serum level of progesterone increased markedly to reach maximal values at late gestation and decreasing at parturition to levels found at early gestation, suggesting that corpora lutea remained functional throughout gestation. These results point out that the unusual ovarian environment of L. maximus in which germ cell demise is abolished through antiapoptotic BCL2 gene overexpression also preserves structural integrity and functionality of corpora lutea during the whole gestation. Overexpression of antiapoptotic BCL2 gene may represent a strategy for an essential need of ovary and corpora lutea in order to maintain pregnancy until term.     

The effect of hadacidin, ultraviolet irradiation of blood (UVB) and thiamine on the prenatal development of Uje:WIST rats: correlation with the hepatic activity of gamma-glutamyltranspeptidase (GGT)]

The influence of hadacidin, a model substance for induction of cheilognathouranoschisis in rat fetuses (2,550 mg/kg b.m. at gestation day 12), ultraviolet irradiation (UVB) of blood (1 week before gestation) and thiamine (25 mg/kg b.m. from gestation days 12 to 15) on the prenatal development of rats at the 20th day of gestation was investigated. Using the body mass and the hepatic GGT-activity as parameters. Hadacidin caused a distinct retardation of the fetal somatic development. Partially, the embryotoxic effect was compensated by UVB or thiamine. The combination of both procedures was more effective. There is a good correlation between the maturation grade of fetuses at day 20 of gestation and the hepatic GGT activity.     

Changes in blood flow distribution during the perinatal period in fetal sheep and lambs.

We have measured total blood flows and blood flows per 100 g tissue to major tissues at 120 and 140 days gestation in fetal sheep and at 3 and 21 days of age in lambs (gestation period = 144 +/- 2 days). Between 120 and 140 days gestation, flow per 100 g tissue increased by 74, 150, and 317% in the renal, intestinal, and hepatic arterial beds, but no further significant change in flow was observed at 3 or 21 days postpartum. Blood flows per 100 g to cerebral hemispheres and cerebellar tissues also increased dramatically during late gestation (142 and 121%, respectively), but declined sharply by 3 days postpartum (73 and 75%, respectively). Brain blood flows at 21 days postpartum remained substantially below late gestational levels. Adrenal blood flows per 100 g more than doubled during late gestation, fell by more than half at birth, and only partially recovered by 21 days of age. Blood flows to carcass tissues did not change in late gestation, fell at birth, then partially recovered. Pre- and post-natal increases in brain blood flows were almost entirely attributable to increased perfusion rather than tissue growth, whereas large perinatal increases in flow to the diaphragm paralleled tissue growth. Tissue growth and increased perfusion per 100 g contributed almost equally to increased blood flows to kidneys postnatally, and to adrenal glands and the gastrointestinal tract prenatally.     

LH response to GnRH infusion in postpartum, fall-lambing ewes subjected to prepartum energy restrictions

Fall-lambing western range ewes were fed either a high-or low-energy ration the last two months of gestation and were fed protein and energy in excess postpartum. GnRH was infused for 10 hours on day 5 or 26 postpartum. Blood samples were collected at 20-minute intervals during infusion and radioimmunoassayed for LH. Net weight change from day 60 prepartum to day 1 postpartum was 0.67 +/- 1 kg vs. -6.9 +/- 1.5 kg (mean +/- SE) for the high-and low-energy groups, respectively (P < 0.05). Nutritional treatment had no effect on LH response at either day 5 or day 26 postpartum, althoughthe day 26 LH response to GnRH was greater (P < 0.05) than the day 5 LH response. LH response was greater (P < 0.05) in ewes that gained weight prepartum vs. ewes that lost weight prepartum, but only in ewes infused on day 5 postpartum.     

Causes of the urinary concentrating defect in mice with nephrogenic diabetes insipidus

In a strain of mice called DI +/+ Severe, nephrogenic (or vasopressin-resistant) diabetes insipidus is caused by an inability of the antidiuretic hormone (ADH, or vasopressin) to increase the water permeability of the renal collecting system. That inability, in turn, arises from abnormally high activity of the enzyme cAMP-phosphodiesterase, specifically of the isozyme type III (PDE-III), which hydrolyzes cAMP and prevents the intracellular buildup of this second messenger. Two rather specific inhibitors of PDE-III, rolipram and cilostamide, used either in vitro or in vivo, reverse the deficiencies in DI +/+ Severe mice by increasing intracellular cAMP and water permeability toward or to their normal values. These results have implications for the treatment of nephrogenic diabetes insipidus in human patients.     

Plasma estrone sulphate (E1S) and estradiol-17beta (E2beta) profiles during pregnancy and their relationship with the relaxation of sacrosciatic ligament, and prediction of calving time in Holstein-Friesian cattle

The objectives of this study were to investigate the plasma E(1)S and E(2)beta profiles during pregnancy and their relationship with the relaxation of sacrosciatic ligament in Holstein-Friesian cattle (n=37) and then to predict the calving time on the basis of E(1)S and E(2)beta profiles and relaxation of the ligament. Blood samples were collected at 4 weeks intervals from days 100 to 190, at 2 weeks intervals from days 190 to 250, every week from days 250 to 270 and thereafter every day from day 270 of gestation until the day after calving. The relaxation in the ligament was measured by using two scales as a distance at a schedule similar to blood sampling plus 5 days postpartum. One scale was kept firm exactly parallel to the ligament between the sacrum and the tuber ischii and other scale was erected perpendicularly to the first scale with the bottom just touching the ligament and the depth was measured in the second scale from the point where it touched the ligament to the point where it touched the first scale. Plasma samples were analyzed for E(1)S and E(2)beta by enzyme immunoassay. E(1)S concentration was low at day 100 (0.8+/-0.3 ng/ml), then increased progressively and drastically to reach the level of 28.4+/-3.6 ng/ml on the day before calving and declined significantly (p<0.05) at 9.5+/-3.1 ng/ml within 1 day postpartum. There was a gradual increase in concentration of E(2)beta from day 100 of gestation (0.1+/-0 ng/ml) until day 4 prepartum (0.6+/-0 ng/ml). Thereafter, it increased drastically and reached the peak level of 1.0+/-0.1 ng/ml (p<0.05) on the day before calving and declined markedly at 0.4+/-0.1 ng/ml within 1 day postpartum (p<0.05). Corresponding to E(1)S and E(2)beta concentrations, a gradual increase in the relaxation of the ligament was observed from day 100 of gestation (8+/-1mm) until day 2 prepartum (24+/-2mm). Thereafter, it showed a significant increase (p<0.05) within 1 day before calving (31+/-2mm) and almost no difference between day 1 prepartum and day 1 postpartum. A marked decrease (p<0.05) was observed thereafter until day 3 postpartum (10+/-2mm) and no significant change between days 3 and 4 as well as 4 and 5 postpartum. The increment of E(2)beta by >or=0.20 ng/ml from the preceding day concentration was 85.2% accurate for predicting calving within 24h in many of the cows (23 of 37) in the herd. The increment in ligament relaxation measurement by >or=5mm from the preceding day measurement was the most efficacious to predict calving within 24h with the highest accuracy (93.9%) in high proportions of cows (31 of 37) in the herd. In conclusion, plasma E(1)S and E(2)beta concentrations and relaxation of sacrosciatic ligament increased gradually as gestation advanced and reached the peak level on the day before calving. The relaxation in the ligament corresponded well to plasma E(2)beta concentrations. Prediction of calving was possible by E(2)beta profile and relaxation in the ligament but not by E(1)S profile. The increment in ligament measurement by >or=5mm from the preceding day measurement was the most useful and accurate in predicting calving within 24h. It is economical and easily applicable in the field condition.     

Variables associated with peripartum traits in dairy cows. III. Effect of diets and disorders on certain blood traits

BLood samples were collected from 89 Holstein cows on days 220 and 250 of gestation, within 24 hr prepartum and postpartum and on day 30 postpartum. Balanced diets which contained either chopped hay (29 cows), hay crop silage (HCS; 30 cows) or corn silage (CS; 30 cows) were fed from day 220 of gestation to day 30 postpartum. The purpose was to determine if variations in certain blood traits were indicative of peripartum and postpartum disorders. The blood traits evaluated were concentrations of plasma total protein, whole blood hemoglobin, packed cell volume, and white blood cells, and serum glutamic oxalacetic transaminase (SGOT), glucose, urea nitrogen, calcium, inorganic phosphorus, magnesium, potassium and sodium. No blood trait was useful to predict a disorder prior to its visual signs with one possible exception. Serum glucose and calcium were lower and SGOT and magnesium were higher peripartum which was prior to death of three cows from fat cow syndrome.     

Nephrogenic diabetes insipidus in an Australian aboriginal kindred.

Four Australian aboriginal children were found to have nephrogenic diabetes insipidus. They are the sons of 3 sisters who were shown to have a urinary concentrating defect uncorrected by vasopressin. An extensive genealogy did not reveal any caucasian genetic influence suggesting that a new genetic mutation was responsible.     

Dynamics of food intake and blood level of hormones regulating appetite in pregnant and lactating mice

Leptin, insulin, corticosterone regulate food intake. Hyperphagia and hormonal rearrangement are typical for pregnancy and lactation. The aim of the study is to correlate food intake with blood levels of these hormones in pregnant and lactating mice. Food intake, body weight, blood glucose, insulin, leptin and corticosterone levels were measured in virgin C57B1/6J micc and on the day 7, 13,17 of pregnancy, and day 1, 7, 14, 30 postpartum. Insulin sensitivity was measured at the day 7, 17 of pregnancy. Food intake and body weight increased towards the second postpartum week and then decreased. Insulin sensitivity decreased towards the end of the pregnancy. Mothers differed from virgin females in hormones and glucose levels only during pregnancy. Leptin level was decreased at the day 7 of gestation, insulin level - during whole gestation. Glucose fell, and leptin and corticosterone increased from the day 7 to 17. Probably, these hormones affect food intake only in pregnant females and do not influence appetite during lactation.     

The 4.5 A structure of human AQP2

Located in the principal cells of the collecting duct, aquaporin-2 (AQP2) is responsible for the regulated water reabsorption in the kidney and is indispensable for the maintenance of body water balance. Disregulation or malfunctioning of AQP2 can lead to severe diseases such as nephrogenic diabetes insipidus, congestive heart failure, liver cirrhosis and pre-eclampsia. Here we present the crystallization of recombinantly expressed human AQP2 into two-dimensional protein-lipid arrays and their structural characterization by atomic force microscopy and electron crystallography. These crystals are double-layered sheets that have a diameter of up to 30 microm, diffract to 3 A(-1) and are stacked by contacts between their cytosolic surfaces. The structure determined to 4.5 A resolution in the plane of the membrane reveals the typical aquaporin fold but also a particular structure between the stacked layers that is likely to be related to the cytosolic N and C termini.     

Spontaneous preeclamptic toxemia of pregnancy in the patas monkey (Erythrocebus patas).

A disease characterized by edema, proteinuria, hypoproteinemia and hypertension was seen in late gestation in patas monkeys. The initial sign was edema of the perineum, ankles and lower trunk. The onset was abrupt, occurring 7 days or less prepartum. The affected animals were not depressed, and convulsions were not seen. In 6 of the 98 pregnancies during a 1-year period, symptoms of the disease were present. The highest incidence was manifested by primiparous animals with 3 of 36 pregnancies affected. Two of 38 second pregnancies and 1 of 24 third pregnancies were also affected. Five of the animals recovered spontaneously and were normal 14 days postpartum. Edema persisted for 30 days in one female. This animal continued to be hypertensive and had persistent mild proteinuria and hypoproteinemia. She was killed approximately 1 year postpartum due to severe renal disease. The spontaneous disease seen in patas monkeys resembled toxemia of pregnancy in humans more closely than the experimentally induced disease in other animals.