Low Urine Specific Gravity Research Articles

8301 A Rare Case of IgG4-Related Hypophysitis

Abstract Disclosure: P. Kesavan Chary: None. J.M. Silverstein: None. Background: IgG4-related disease (IgG4-RD) is an immune-mediated condition that presents as systemic inflammation and fibrosis of tissues, often affecting multiple organs. Isolated IgG4-related Hypophysitis is rare and characterized by lymphoplasmacytic infiltration of the pituitary gland by IgG4-positive plasma cells. A combination of clinical, serologic, radiologic, and histopathologic findings is used for diagnosis of IgG4-RD and approximately two-thirds of all patients have elevated serum IgG4 levels. We report a case of isolated IgG4-related Hypophysitis in a middle-aged woman serologically negative for IgG4-related disease. Case Report: A 52 year old female with history of steroid dependent severe persistent asthma, allergic rhinitis, and chronic sinusitis presented with one month of headache, polyuria, and polydipsia. MRI Brain demonstrated an enlarged, rounded pituitary gland 16 x 11 x 9 mm, with homogeneous enhancement, extension into the suprasellar cistern, and mild thickening of the infundibulum suspected to represent a pituitary adenoma. Lab evaluation revealed mild hyperprolactinemia (prolactin 83.2, normal 4.8-23.3 ng/mL) and secondary adrenal insufficiency based on an abnormal high-dose cosyntropin stimulation test in the setting of a low adrenocorticotrophic hormone (ACTH) level (<2.0 pg/mL). Remaining pituitary hormone levels were normal. Inpatient work-up for polyuria and polydipsia showed a low urine specific gravity of 1.003. An overnight water deprivation test was performed. Baseline urine osmolality (UOsm) was 95 mOsm/kg and serum sodium was 144 mmol/L; after 3 hours of water deprivation, serum Osm increased to 301 mOsm/kg (275-300 mOsm/kg) and UOsm only to 215 mOsm/kg, while her sodium increased to 145 mmol/L. Results were felt to be consistent with AVP deficiency (Central Diabetes Insipidus) and the patient was started on desmopressin. Because of the presence of AVP deficiency, further work-up was done to evaluate for an infiltrative process or malignancy. ANA, RPR, ESR, CRP, CBC, ACE level, T-SPOT, and IgG subclasses were unremarkable. Further imaging studies yielded a negative nuclear bone scan and PET/CT scan. For diagnostic purposes, the patient underwent biopsy via an endoscopic endonasal transsphenoidal approach. Pathology showed the presence of >10 IgG4+ plasma cells in a single high-power field, consistent with a diagnosis of IgG4-related Hypophysitis. Conclusion: Isolated IgG4-related Hypophysitis is the least common clinical presentation of IgG4-RD, which is itself a rare and relatively newly recognized condition. IgG4-related Hypophysitis should be suspected in patients presenting with AVP deficiency and pituitary stalk enlargement with an otherwise negative work up. Presentation: 6/2/2024

Predictive Value of C-reactive Protein in the Spontaneous Passage of Lower Ureteric Stones: A Prospective Single-Centre Study.

Ureteric stones, characterised by their presence in the ureter, present a common yet often painful urological condition requiring timely intervention. As C-reactive protein (CRP) emerges as a potential biomarker, its correlation with the spontaneous stone passage(SSP) offers valuable insights into patient management and treatment strategies. The present study aimed to assess if CRP levels can predict SSP in symptomatic lower ureteric calculi of size 5 mm-10 mm. This prospective observational study, conducted at the Indira Gandhi Institute of Medical Sciences in Patna, India, from July 2022 to June 2023, focused on individuals aged 13 to 60 years presenting with ureteric colic and single distal ureteral stones (5 mm-10 mm). Patients underwent comprehensive initial assessment and monitoring, including diagnostic procedures such as a complete blood count, urinalysis, CRP levels, and renal function evaluations. Treatment consisted of hydration encouragement, tamsulosin (0.4 mg) daily administration, and diclofenac (50 mg) as needed. Follow-up assessments at one-month post-treatment involved clinical examination and imaging studies to evaluate treatment efficacy. This study analysed 157 patients with ureteric stones, finding that 76% experienced SSP. Lower CRP levels (≤6 mg/L), along with other laboratory parameters like low white blood cell counts, low neutrophil levels, absence of leukocyturia, absence of hematuria, and lower urine specific gravity, were associated with higher SSP rates. C-reactive protein levels ≤6 mg/L emerged as a strong predictor of SSP in multiple regression analysis. The findings underscore the potential utility of CRP as a predictive biomarker in guiding the management and treatment strategies for ureteric stones.

Fully Endoscopic Minimally Invasive Trans-Eyebrow Supraorbital Translaminar Approach to Third Ventricle Craniopharyngiomas: Technical Nuances and Stepwise Illustrative Description

BackgroundTraditional microsurgical approaches for addressing intraventricular craniopharyngioma pose limited access to the retrochiasmatic area and tumors with significant lateral or rostrocaudal extensions. Extended endoscopic endonasal approaches can effectively overcome many of limitations, yet they require a favorable angle between the optic chiasm and pituitary gland, as well as the involvement of the third ventricle floor by the tumor. MethodsHerein, the authors describe the surgical nuances of a keyhole technique for resecting third ventricle craniopharyngiomas via a fully endoscopic minimally-invasive trans-eyebrow supraorbital translaminar approach (ESOTLA). A case description detailing the approach’s application is provided, along with a series of cadaveric photographs to highlight the relevant anatomy and step-by-step dissection process. ResultsThe patient is a 44-year-old man who presented with polyuria, low urine specific gravity, hypogonadism, and hypopituitarism. Brain MRI revealed a solid-cystic heterogeneous-enhanced retrochiasmatic mass within the third ventricle, consistent with craniopharyngioma. A one-stage ESOTLA was indicated based on the narrow corridor between the pituitary gland and optic chiasm and the high functional status of the patient. Near-total resection was achieved, and no new postoperative neurologic or endocrine deficit was observed. Targeted therapy was implemented based on the histologic result, and the most recent surveillance MRI showed no evidence of the residual tumor. ConclusionsBy combining a keyhole approach with variable-angle endoscopic visualization through a smaller bony and soft tissue exposure, ESOTLA can provide enhanced illumination within the third ventricle, potentially addressing cosmetic concerns and limited exposure area and angle of freedom associated with its conventional microsurgical counterpart.

Densidade urinária como um indicador para determinação da GGT urinária em cães com leishmaniose visceral

The urinary Gama-Glutamyl Transpeptidase to urinary Creatinine ratio (uGGT/uCR) is a laboratory marker that may signal renal tubular lesion in dogs with visceral leishmaniasis (VL). In this study, our goal was to determine whether urine specific gravity (USG) can accurately indicate an elevated uGGT/uCR and, consequently, tubular injury. Twenty-eight animals with VL and five healthy animals (control group) were included in the study. The diseased animals were classified as azotemic (n = 6) and non-azotemic (n = 22). The difference between all groups was tested with the Kruskal-Wallis test for the USG, uGGT/uCR, and urine protein: creatinine ratio (UPC). Sensitivity, specificity, positive and negative predictive value and the accuracy of using USG as an indicator of tubular injury were calculated with the Receiver Operating Characteristic (ROC curve). The probability of an animal with suboptimal USG presenting tubular injury was obtained by calculating the prevalence ratio. The Kruskal-Wallis test revealed differences between groups for all analyzed parameters (p< 0.05). The chosen USG cut-off value, determined by the ROC curve was 1.030, with an accuracy of 78.09%. The probability of a dog with LV and USG below 1.030 having a high uGGT/uCR ratio was 4.95 (p <0.01, 95% CI - 1.32-18.48) when compared to individuals with ideal DU. In conclusion, dogs positive for Leishmania sp. with low USG (<1.030) should have their uGGT/uCR ratio measured to verify the presence of tubular injury even before the onset of azotemia.

Clinical and biochemical alterations associated with excess calcitonin in a dog with medullary thyroid carcinoma

AbstractWe present a 10‐year‐old mongrel dog with progressive weight loss, polyuria and polydipsia. Physical examination revealed poor body condition, systemic hypertension (on average 165 mmHg) and a cervical mass that was confirmed by ultrasound in the right thyroid lobe (diameter 4.0 cm). Blood biochemistry on two different days revealed a low ionised calcium concentration (1.1 and 0.81 mmol/L; reference range: 1.1–1.3 mmol/L) associated with an elevated plasma calcitonin concentration in the same sample (44.8 and 49 pg/mL; reference range: <2 pg/mL). A low urine specific gravity (1.012) was also found. Total thyroxine concentration was low, corresponding to euthyroid sick syndrome. Hypercalcitoninemia, hypocalcaemia and clinical signs resolved after an uncomplicated right thyroidectomy. Positive staining of the neoplasm for calcitonin on immunohistochemistry confirmed a medullary thyroid carcinoma. This is the first report describing the clinical signs and biochemical alterations associated with excess calcitonin in a dog with medullary thyroid carcinoma confirmed by immunohistochemistry.

The Relationship Between Manifestation of Diabetes Insipidus and Estimated Glomerular Filtration Rate in Brain Death.

Systematic reviews have revealed that up to 50% of patients with brain death have residual hypothalamic/pituitary activity based on the absence of central diabetes insipidus (DI). We hypothesized that different degrees of renal dysfunction may impact the presence of DI in patients with brain death. Single-center prospective data collection. ICUs in a tertiary academic hospital. All adult patients declared brain dead over 12 years. None. DI was diagnosed by polyuria, low urine specific gravity, and increasing serum sodium, measured in close proximity. Renal function was assessed by the estimated glomerular filtration rate (eGFR), calculated using the simplified modification of diet in renal disease equation. Analysis was completed in 192 of 234 patients with brain death after excluding those with missing data, those younger than 18 years and those on vasopressin infusions. One hundred twenty-two patients (63.5%) developed DI and 70 patients (36.5%) did not. The proportion of DI decreased significantly with decreasing eGFR: for eGFR greater than 60 mL/min, DI was present in 77.2%; for eGFR 15-60 mL/min, DI was present in 54.5%; for eGFR 14.9-9.8 mL/min, DI was present in 32%; none of the 14 patients with eGFR less than or equal to 9.7 mL/min ever experienced DI ( p < 0.001). Using logistic regression, for every 10 mL/min decrease in eGFR, the odds of DI decreased 0.83 times (95% CI, 0.76-0.90, p < 0.001). Renal dysfunction significantly impacts DI's clinical manifestation in brain death. We report that patients who experience brain death with severe renal dysfunction may not develop clinical signs of DI.

THU106 Malignant Epithelioid Neoplasm As The Cause Of A Rapidly Growing Pituitary Mass

Abstract Disclosure: S. Riahi: None. S.S. Chaidarun: None. Background: Malignant epithelioid neoplasm is a rare cause of a pituitary mass, and should be kept on the differential whenever evaluating patients with evidence of rapid pituitary enlargement. Clinical Case: A 43 year-old man presents with 3-month history of worsening severe headaches, decreased libido, erectile dysfunction, polydipsia, polyuria (6L/day) with nocturia every hour, and fatigue. He also noted some blurry vision without loss of his peripheral vision. MRI of the brain showed a 1.5cm mass in the sellar and suprasellar region abutting the optic chiasm. Of note, he had a brain MRI performed 18 months prior for vertigo which did not demonstrate any mass in the pituitary. He presented to the endocrinology office for evaluation. His laboratory tests demonstrated mildly elevated prolactin 31.2 ng/mL (n 4.0-15.2), and findings consistent with panhypopituitarism and central diabetes insipidus, including low FT4 of 0.46 ng/dL (n 0.93-1.70), FSH 0.7 mIU/mL (n 1.5-12.4), an undetectable LH (n 1.7-8.6mIU/mL), random cortisol of 1mcg/dL (n 4.8-19.5) ACTH 6.2 pg/mL (n 7.2-63), IGF-1 of 139 ng/mL (n 44-275), total testosterone undetectable (n 240-950 ng/dL), sodium 144mmol/L (n 135-145) with low urine specific gravity 1.008 and urine osmolality of 143mOsm/Kg (n 60-1200). HCG was undetectable (n 0-2mIU/mL) but LDH was elevated at 313 unit/L (n 110-220). He was started on corticosteroids, levothyroxine, DDAVP, and referred to neurosurgery. Specimens from his transphenoidal biopsy demonstrated findings consistent with a malignant epithelioid neoplasm. Further analysis and genetic testing is still pending. He has been referred to oncology service for further management and care. Conclusion: A rapidly growing symptomatic pituitary mass with central diabetes insipidus should raise suspicion for malignant etiology beyond the more prevalent pituitary adenoma. Malignant epithelioid neoplasm are uncommon tumors of the brain, however they are known to be aggressive tumors with high mortality. Treatment commonly includes some combination of surgery, radiotherapy, and chemotherapy1. Reference: (1) Jog AP, Ronderos DM, Ali A, Niazi M, Diaz-Fuentes G. Malignant Epithelioid Neoplasm of the Brain. Cureus. 2020 Aug 27;12(8):e10079. doi: 10.7759/cureus.10079. PMID: 33005505; PMCID: PMC7523542. Presentation: Thursday, June 15, 2023

SAT590 Complex Migraine Manifesting As CDI - A Rare Occurrence

Abstract Disclosure: M. Shahid: None. E. Sari: None. W. Timirau: None. A. Hamza: None. N. Guzman: None. S. Sultan: None. Introduction: There are many references in the literature to unexplained neurological symptoms occurring with complex migraines, however, complex migraine manifesting as central diabetes insipidus (CDI) is rare. Clinical Case: A 48-year-old female with past medical history of psoriatic arthritis, generalized anxiety disorder, and migraine presented with the worst headache of her life for 2 days, typical for her migraine but with increased severity, and minimally responsive to NSAIDs. Her headache was accompanied by nausea, photophobia, floaters, polydipsia and polyuria. She denied any neck pain/rigidity, focal deficits, or head trauma. She reported a similar episode with lesser severity 10 days ago which resolved in 3 days. She related her headache episodes with polyuria. Her medications included topiramate, escitalopram, apremilast, loratadine, and NSAIDs. She denied any new medications. Physical examination was unremarkable. Initial labs showed high-normal sodium 145 mMol/L, normal serum osmolality 292 mOsm/kg, low urine specific gravity 1.003, and low urine osmolality 117 mOsm/kg and urine sodium 32.4 mMol/L. HbA1c, B-hCG and urinalysis were normal. CT brain, CTA head and neck, MRI brain with/without IV contrast, and CSF analysis were unremarkable. The patient was started on abortive treatment for migraine. She had a negative fluid balance of 1500ml during first 24 hours. Polyuria did not resolve with water restriction but resolved with improvement of migraine; which favored the diagnosis of complex migraine manifesting with polyuria secondary to CDI. Patient was discharged on migraine prophylaxis and neurology follow-up. Conclusion: Link between migraine and endocrinological disorders has been well identified. Even though most cases are idiopathic, any disorder that acts at the hypothalamic-pituitary axis involved in ADH secretion can cause CDI, however migraines as an etiology remains rare. Early recognition of symptoms, treatment of migraine and introduction of migraine prophylaxis was crucial in our case to prevent further episodes of CDI. Presentation: Saturday, June 17, 2023

Urine concentrating ability in cats with hyperthyroidism: Influence of radioiodine treatment, masked azotemia, and iatrogenic hypothyroidism.

Hyperthyroid cats often have urine specific gravity (USG) values <1.035. It remains unclear how USG changes after treatment, if USG can be used to predict azotemia after treatment, or how iatrogenic hypothyroidism influences USG values. To determine the proportion of hyperthyroid cats with USG <1.035 vs ≥1.035; if USG changes after treatment; and whether USG <1.035 correlated with unmasking of azotemia or hypothyroidism. Six hundred fifty-five hyperthyroid cats treated with radioiodine; 190 clinically normal cats. Prospective, before-and-after study. Hyperthyroid cats had serum thyroxine, thyroid-stimulating hormone, and creatinine concentrations, and USG measured before and 6 months after successful treatment with radioiodine. Of untreated hyperthyroid cats, USG was ≥1.035 in 346 (52.8%) and <1.035 in 309 (47.2%). After treatment, 279/346 (80.6%) maintained USG ≥1.035, whereas 67/346 (19.4%) became <1.035; 272/309 (88%) maintained USG <1.035, whereas 37/309 (12%) became ≥1.035. Only 22/346 (6.4%) with USG ≥1.035 developed azotemia after treatment, compared with 136/309 (44%) with <1.035 (P < .001). Of cats remaining nonazotemic, 38% had USG <1.035, compared with 20% of normal cats (P < .001). The 137 cats with iatrogenic hypothyroidism had lower USG after treatment than did 508 euthyroid cats (1.024 vs 1.035), but USGs did not change after levothyroxine supplementation. USG <1.035 had high sensitivity (86.1%) but moderate specificity (65.2%) in predicting azotemia after treatment. Hyperthyroidism appears not to affect USG in cats. However, cats with evidence of sub-optimal concentrating ability before radioiodine treatment (USG < 1.035) are more likely to develop azotemia and unmask previously occult chronic kidney disease. Iatrogenic hypothyroidism itself did not appear to affect USG values.

Primary hyperoxaluria: A case report

Renal failure can occasionally be caused by oxalate nephropathy. Glyoxylate metabolism abnormalities and particular hepatic enzyme deficits are the causes of primary hyperoxaluria (PH). Increased intestinal absorption, an excessive diet or an increased intake of oxalate precursors can all result in secondary hyperoxaluria. A 13-month old male child with high blood creatinine, low sodium, low calcium levels, high uric acid and low urine specific gravity is the subject of this research. Medullary papillary calcification was detected using sonography (nephrocalcinosis). Calcium oxalate crystals, sparse lymphocytic infiltration and interstitial fibrosis were seen on a renal biopsy. The patient was put on peritoneal dialysis, progresses to anuria and expired due to renal failure.

Clinicopathological Findings in Cats Tested for Feline Immunodeficiency Virus (FIV) and Feline Leukaemia Virus (FeLV)

Abstract This retrospective study aimed to evaluate the clinicopathological changes in a population of cats tested for feline immunodeficiency virus (FIV) and feline leukaemia virus (FeLV), in an Italian Veterinary University Hospital, in the period between January 2002 and May 2016. During the period of 14 years, 1834 cats were tested, and of these 241/1834 (13.1%) were positive for FIV antibodies and 92/1834 (5%) cats were positive for FeLV antigen. These data confirm the presence of a high prevalence of these viruses on Italian territory. To the authors’ knowledge, this study describes findings that have never been evaluated before, such as iron status in retrovirus-infected cats and urinalysis in FeLV-positive cats. In this study, FIV-positive cats were more likely to have higher serum protein concentration and lower albumin-globulin ratio than other groups of cats. Lower urine specific gravity and higher urine protein to creatinine ratio were also detected for FIV-positive cats when compared with negative and healthy cats. FeLV-positive cats were more likely to have cytopenia, decreased haemoglobin, haematocrit and RBC compared with other groups of cats. The data obtained underline the importance of considering retroviral infections in the presence of a broad spectrum of risk factors and laboratory anomalies.

A comparison of the utility of the urine dipstick and urine protein-to-creatinine ratio for predicting microalbuminuria in patients with non-diabetic lifestyle-related diseases -a comparison with diabetes

BackgroundThe utility of dipstick proteinuria for predicting microalbuminuria in non-diabetic lifestyle-related diseases compared with the urine protein-to-creatinine ratio (uPCR) and the effect of dipstick proteinuria on the cut-off value (CO) and accuracy of uPCR are unclear.MethodsThe subjects included Japanese patients ≥ 18 years old with lifestyle-related diseases who had an estimated glomerular filtration rate of ≥ 15 ml/min/1.73 m2 and uPCR of < 0.5 g/gCr at initiation. Urine dipstick, uPCR and urine albumin-to-creatinine ratio (uACR) were measured three times per case. Microalbuminuria was defined as uACR of 30–299 mg/gCr for at least 2 of 3 measurements. Youden’s Index was used as the optimal CO. Factors associated with microalbuminuria were analyzed using a logistic regression model.ResultsIn 313 non-diabetic cases (median 70.8 years old), 3 dipstick proteinuria measurements were independently useful for detecting microalbuminuria, and the CO was set when a trace finding was obtained at least 1 of 3 times (sensitivity 0.56, specificity 0.80, positive predictive value [PPV] 0.73, negative predictive value [NPV] 0.65). A single uPCR measurement was more useful than 3 dipstick measurements, and was useful for detecting microalbuminuria even in cases with three consecutive negative proteinuria findings, indicating that the CO of the second uPCR with G1-3a (n = 136) was 0.06 g/gCr (sensitivity 0.76, specificity 0.84. PPV 0.68, NPV 0.89), while that with G3-b4 (n = 59) was 0.10 g/gCr (sensitivity 0.56, specificity 0.91. PPV 0.83, NPV 0.71). The sum of 3 uPCRs was useful for detecting microalbuminuria in cases with G1-3a (sensitivity 0.67, specificity 0.94, PPV 0.82, NPV 0.86) and G3b-4 (sensitivity 0.78, specificity 0.94, PPV 0.91 NPV 0.83), with both COs being 0.23 g/gCr. These COs of microalbuminuria did not change when trace or more proteinuria was included, although the sensitivity increased. A high uPCR and low urine specific gravity or creatinine level were independent factors for uACR ≥ 30 mg/gCr in cases with negative proteinuria, although the uPCR was a major predictive factor of a uACR ≥ 30 mg/gCr.ConclusionsThe uPCR (preferably determined using early-morning urine), including in dipstick-negative proteinuria cases with non-diabetic lifestyle-related diseases, can aid in the early detection of microalbuminuria.Trial registrationRetrospectively registered.

Normotensive primary hyperaldosteronism due to an adrenocortical adenoma in a dog

AbstractWe present an 8‐year‐old poodle with polyuria, polydipsia and muscle weakness. Physical examination revealed no abnormalities. Laboratory alterations were hypokalemia and hypernatraemia with a low urine specific gravity. Abdominal ultrasound revealed a nodule in the right adrenal gland (diameter 0.95 cm). Systolic blood pressure was normal for several consecutive days (on average 120 mmHg). Elevated plasma aldosterone and undetectable plasma renin concentrations were diagnostic of primary hyperaldosteronism. An uncomplicated adrenalectomy was performed. Histopathological examination revealed an adrenocortical adenoma with positive expression for neuron‐specific enolase but not for synaptophysin and chromogranin on immunohistochemistry. In addition, immunostaining for neuron‐specific enolase was also found in cells from the normal glomerular zone of the same adrenal gland. Therefore, zona glomerulosa origin of the neoplasm was inferred. Adrenalectomy normalised laboratory abnormalities with remission of clinical signs. This report highlights the importance of not excluding the diagnosis of primary hyperaldosteronism in the absence of arterial hypertension.

The Effects of Water Provision and Education on Students’ Hydration Status, Cognitive Abilities, and Fine Motor Function in A Full-Day Primary School

Background/aim: Dehydration due to inadequate water intake in children may disrupt brain functions. This study aimed to investigate the effects of hydration education with water provision on hydration status, cognitive functions and motor performance. Materials and Methods: Forty-eight children in primary full-day school (age 8 – 11 years) were recruited in this study. The intervention of hydration education was performed for two days, both for students and teachers. The water was provision for 12 days. Letter cancellation task (LCT), symbol digit modalities test (SDMT), and direct image different test (DIDT) were used to assess cognitive functions. Motor performance was evaluated using a finger tapping test (FTT). Hydration status was determined with urine specific gravity (USG) and urine color (UC). Before and after interventions, all parameters were evaluated.Results: Most students found dehydrated (&gt;65%). The students had lower USG and UC after the intervention and it was correlated with each other (before; rs=0.45, P = 0.001 and after; rs=0.82, P = 0.001). All cognitive and motor functions were significantly higher after an intervention (P &lt; 0.05). Conclusion: Hydration education to students and teachers combined with water provision at primary full-day school increases hydration status and enhances cognitive and fine motor skills.

Transcriptomic Analysis Reveals that Activating Transcription Factor 3/c-Jun/Lgals3 Axis Is Associated with Central Diabetes Insipidus after Hypothalamic Injury

Background: Hypothalamic injury causes several complicated neuroendocrine-associated disorders, such as water-electrolyte imbalance, obesity, and hypopituitarism. Among these, central diabetes insipidus (CDI), characterized by polyuria, polydipsia, low urine specific gravity, and deficiency of arginine vasopressin contents, is a typical complication after hypothalamic injury. Methods: CDI was induced by hypothalamic pituitary stalk injury in male animals. Behavioral parameters and blood sample were collected to evaluate the characteristics of body fluid metabolism imbalance. The brains were harvested for high-throughput RNA sequencing and immunostaining to identify pathophysiological changes in corresponding hypothalamic nuclei. Results: Based on transcriptomic analysis, we demonstrated the upregulation of the activating transcription factor 3 (Atf3)/c-Jun axis and identified Lgals3, a microglial activation-related gene, as the most significant target gene in response to the body fluid imbalance in CDI. Furthermore, we found that the microglia possessed elevated phagocytic ability, which could promote the elimination of arginine vasopressin neurons after hypothalamic injury. Conclusion: Our findings suggested that the Atf3/c-Jun/Lgals3 axis was associated with the microglial activation, and might participate in the loss of functional arginine vasopressin neurons in CDI after hypothalamic injury.

Feline Morbillivirus in Southern Italy: Epidemiology, Clinico-Pathological Features and Phylogenetic Analysis in Cats.

Feline morbillivirus (FeMV) was isolated for the first time in 2012 with an association with chronic kidney disease (CKD) suggested. This study aimed at investigating in cats from southern Italy FeMV prevalence and risk factors for exposure to FeMV, including the relationship with CKD; sequencing amplicons and analyzing phylogeny of PCR positive samples. Blood serum, K3EDTA blood and urine samples from 223 cats were investigated. Ten carcasses were also evaluated. FeMV RNA was detected in 2.4% (5/211) blood and 16.1% (36/223) urine samples. One carcass tested positive by qPCRFeMV from kidney, urinary bladder, and submandibular lymph nodes. Antibodies against FeMV were detected in 14.5% (28/193) cats. We followed up 27 cats (13 FeMV positive cats) and documented in some cases urine shedding after up to 360 days. Older and foundling cats and cats living in rescue catteries, were more frequently infected with FeMV. A significant correlation between FeMV and higher serum creatinine values or low urine specific gravity was found. FeMV positivity was significantly associated with retroviral infection, and the presence of some clinical signs apart from CKD clinicopathological markers. Our study highlights the possibility of a link between FeMV exposure and CKD and a general impairment of feline health.

Increased Water Viscosity Enhances Water Intake and Reduces Risk of Calcium Oxalate Stone Formation in Cats.

Simple SummaryIncreasing water intake and decreasing urine concentration are recommended for cats that form stony concretions in the bladder or urinary tract. The purpose of this study is to determine if water with increased viscosity results in increased water intake in cats by taking advantage of the unique anatomy of the cat’s tongue. Cats delicately dip their tongue into water, pull their tongues back up to their mouths, and capture the water that follows. Lapping occurs by fluid adhesion to the dorsal part of the tongue’s tip and by lifting a liquid column through the tongue’s upward motion before jaw closure. Cats have the ability to balance gravity and water surface tension to ingest the maximum amount of water per lap. This observation led us to question whether changing the properties of water in a way that allows cats to lift more water per lap is possible. Increasing the viscosity of water was accomplished with 1% methylcellulose, an ingredient that is palatable to cats. Cats consuming 1% methylcellulose water had increased water intake (25% and 21% higher at 28 and 56 days, respectively), and increased water intake reduces the risk for calcium oxalate stone formation. The benefit of giving cats viscous water is that they can increase water consumption without having to change their natural drinking behavior. The purpose of this study is to determine if water with increased viscosity results in increased water intake, thus lowering the risk of urolithiasis in cats. Twelve healthy adult cats were fed pre-trial standard dry maintenance food for 1 week and then randomized into two groups for the study phase. The cats continued to receive the same food but were provided either control (deionized) water or viscous (1% methylcellulose) water for two months and then switched to the other water type for two months in a cross-over study design with repeated measures. Complete blood counts, serum chemistry profiles, and urinalysis were performed at the initiation of the study and again at 1, 2, 3, and 4 months. Daily water consumption and energy intake for each cat were recorded. Body weights were assessed weekly. Cats consuming 1% methylcellulose water with increased viscosity had increased water intake (p < 0.001; 25% and 21% higher at 28 and 56 days, respectively). Increased consumption of water resulted in lower urine specific gravity (p = 0.04), serum creatinine (p = 0.02), and blood urea nitrogen (p = 0.002) concentrations (without changing serum albumin, glucose, and calcium concentrations or serum osmolality) and decreased urine calcium concentration (p = 0.01) compared with cats consuming control water. In addition, the increased water intake increased (p = 0.05) resistance to oxalate crystal formation.

Interesting and Rare Case of Central Diabetes Insipidus in a Patient With Acute Myeloid Leukemia

Introduction: Central Diabetes Insipidus (CDI) is the lack of antidiuretic hormone (ADH) leading to impaired urinary concentration and manifests with extreme thirst and excessive urination. Patients unable to drink fluids are at risk of severe dehydration and hypernatremia. CDI can be a rare complication of acute myeloid leukemia (AML). The occurrence of AML with CDI is extremely rare with only few case reports published. This combination of AML with CDI has been reported to be associated with monosomy 7 and inversion (3) (q21q26) and portends an overall a very poor treatment response resulting in poor outcomes.Case Presentation: 66-year-old female with hypertension, polycythemia vera diagnosed in 2006 with transformation to AML in 2020. FISH studies revealed monosomy 7. Cytogenetic studies showed inv (3)(q21q26.2). Remission induction chemotherapy was initiated. Subsequently, neutropenic fever and sepsis secondary to Clostridium difficile colitis lead to hospitalization. Her sodium (Na) level gradually trended up and reached a peak of 157 mmol/l (range 136-145) and elevated serum osmolality at 311 mOsm/K with low urine osmolality 135 mOsm/K, low urine sodium at 13 and low urine specific gravity 1.006 concerning for CDI. She developed polyuria and received desmopressin (DDAVP) leading to improvements in urine osmolality to 267 mOsm/K, 30 minutes indicating CDI diagnosis. Her Na gradually normalized to 144 mmol/l, urine osmolality improved to 580 mOsm/K and urine specific gravity to 1.025. She is now on DDAVP 0.05 mg oral twice daily and her Na is in normal range. MRI pituitary did not show any evidence of metastatic lesion with intact pituitary bright spot. Her other pituitary hormonal workup was normal except for hypogonadotropic hypogonadism.Discussion: The pathophysiology of AML and CDI is unclear. Leukemic cells infiltration of the neurohypophysis; thrombosis of small vessels in hypothalamic nuclei and the posterior pituitary; alterations of the neutrophil migration placed on the chromosome 7 leading to glycoprotein gp 130 production, a cell surface marker on granulocytes are some of hypothesis suggested. CDI has a variable onset in the course of myeloid malignancies. MRI pituitary can be normal in most of the cases.

The Sodium See-Saw: Prolonged Second Phase of Diabetes Insipidus and Complete Resolution Following Surgical Resection of a Supra-Sellar Meningioma

Abstract Background: Diabetes insipidus (DI) is a common occurrence after sellar/suprasellar surgery. However, signs of recovery after a few days should be treated with caution as this may precede a “triple response”, seen in 3.4% of the patients. In this response, initial postoperative DI gives way to a period of remission or clinically inappropriate antidiuresis before eventual recurrence of DI. Clinical Case: A 38-year-old Hispanic female was admitted to the hospital for elective transcranial resection of a suprasellar meningioma extending along the planus sphenoidale, measuring 23x19x17mm. Preoperatively, all pituitary hormones were in the normal range. On POD1, she was noted to have polyuria with urine output of &amp;gt;400ml/h, uptrending sodium levels (148, RR: 135-145mmol/L), low urine specific gravity (&amp;lt;1.005, RR:1.005-1.030) and low urine osmolality (82, RR:300-900mOsm/kg). She was diagnosed with DI and was treated with DDAVP over the following three days. Follow-up MRI was done. In addition to post-surgical changes, it showed acute ischemia in the region of the anterior commissure. After short-term improvement in her clinical status, she was noted to have decreased thirst and decreased urine output on POD6. Sodium was low at 132mmol/L. Urine specific gravity was 1.017. Serum osmolality was 258 mOsm/kg (RR:279-300 mOsm/kg). There was concern for developing SIADH vs concurrent adrenal insufficiency. Patient had received methylprednisolone perioperatively, hence AM cortisol testing would have been inaccurate. Fluid restriction, along with empiric glucocorticoid replacement, was initiated. Sodium continued to worsen with nadir of 122mmol/L and patient reported new onset headache. She was started on 3% (hypertonic) saline continuous infusion and salt tablets. Hyponatremia gradually resolved by POD13, 7 days after onset of SIADH. Salt tablets and fluid restriction were discontinued. Patient was seen in clinic on POD17 and reported normal thirst and urine output. Sodium was noted to be 143mmol/L. Conclusion: This case highlights the rare presentation of a partial triphasic sodium imbalance after resection of a suprasellar mass, with a prolonged second phase lasting for 7 days. A few studies have reported that it may last longer when pituitary gland is not damaged preoperatively, as was the case in our patient. Similarly, complete recovery may also occur if the hypothalamus and pituitary are normal preoperatively. Postoperatively, patient was noted to have an anterior commissural ischemia. This could have contributed to the fluctuations in ADH secretion, due to the rostral proximity of the hypothalamus to the anterior commissure. Despite adequate measures, sodium may continue to drop dramatically in the second phase. Patients should be monitored for changes in thirst and normalization of urine output, as these may indicate early symptoms of impending SIADH before hyponatremia develops.

The predictive value of urine specific gravity in the diagnosis of vasovagal syncope in children and adolescents

BackgroundVasovagal syncope (VVS) is a kind of common neurally mediated syncope in children and adolescents. Decreased blood volume is one of the pathogenesis of VVS. The diagnosis of VVS is mainly based on head-up tilt test (HUTT), but some complications may easily occur when HUTT induces syncope. To find a simple and safe VVS diagnosis method can improve the VVS diagnosis efficiency.Aims of the studyThis was a prospective study. The study will explore the predictive value of urine specific gravity (USG) in the diagnosis of VVS in children and adolescents.Patients and methodsNinety-seven cases (43 males and 54 females, aged 4 to 16 years old, with an average age of 10.91 ± 2.18 years old) hospitalized due to unexplained premonitory syncope or syncope and diagnosed with VVS through HUTT from September 2014 to September 2018 were selected as VVS group. During the same period, 91 cases of children and adolescents, including 45 males and 46 females, aged from 5 to 15 years old, who underwent a healthy examination were matched as a control (control group). USG was measured in both groups.ResultsThe USG of VVS group was significantly lower than that of the control group (P < 0.01), and USG of females was lower than that of males in VVS group (P = 0.045). The sensitivity and specificity of USG in predicting VVS were evaluated by ROC curve. The area under the ROC curve was 0.751, standard error was 0.035, and 95% CI (0.683, 0.819) suggested that USG was of moderate predictive value in the diagnosis of VVS. As cut-off value of USG was 1.0185, the sensitivity and specificity and diagnostic coincidence rate of VVS were 74.39, 66.04 and 69.68%, respectively.ConclusionThere are less USG in children and adolescents with VVS, especially lower USG in females. Therefore, USG has predictive value in the diagnosis of VVS in children and adolescents.