C.

D, 43 years, male First admission in our department in september 2012

Complains:
polyuria-polydipsia with onset about 6-7 wks ago(6-8 l/24h) cronic fatigue syndrome constipation

 Family history: Her parents with cardiac pathology Personal history: without a history of significant pathological Non smoker No chronic medication use Course of the disease: The patient without significant previous history accuses polydipsia (6 8 l / 24h) and polyuria wich appeared insidious about 6-7 weeks ago, with progressive character associated with fatigue and constipation.

Clinical exam
Expressive face Normal skin color H: 174 cm; W: 76,5 kg; BMI: 25,33 kg/m Muscles weakness. BP: 110/80 mmHg, HR: 70/min Gastrointestinal app.: polydipsia,constipation Genitourinary app.: polyuria, nicturia

Endocrine system
Hypothalamo-pituitary system: Pituitary tumor syndrome:

neurological syndrome: no signs or symptoms opto-chiasmatic syndrome: no signs or symptoms imagistic findings: discussed at paraclinical findings endocrine syndrome: polyuria-polydipsia, nicturia

Thyroid gland: normal size and consistency Parathyroid glands: constipation, muscle weakness Adrenal glands: muscle weakness

Presumptive diagnosis:
Polyuro-polydipsic syndrome

What lab test you need?

Lab tests
Blood Count: Leuc: 6.600/ml, Hgb 16.1 g/dl, Htc 49.4 %, PLT 268.000 ml, Ionogram: Ca total : 11,3 mg/dl , P: 2.18 mg/dl , Mg: 2.09 mg/dl ; Na: 144 mmol/l; K: 4.1 mmol/l Total cholesterol: 193 mg/dl; triglycerids: 110 mg/dl Glycemia: 89 mg/dl . Uric acid: 6.11 mg/dl Creatinine: 0.88 mg/dl, Uree: 23.4 mg/dl Normal liver enzymes. Alkaline phosphatase: 182 u/l Urinary balance sheet: Bil: neg, UBG: normal, KET: neg, ASC: neg, GLU: normal, PROT: neg, ERY: neg, PH: 6, Density: 1000; Urinary Ca : 456.24 mg/24 h , Urinary P: 998.16 mg/24 h

Hormonal assessment
PTH: 120.9 pg/ml (15-65)
Ca total : 11.3 mg/dl, P:2.18mg/dl, Magnesium: 2.09 mg/dl
TSH: 1.27 UI/ml (0.38-4.31) FT4: 0.91 ng/dl (0.82-1.63) Cortisol 8 am: 16.4 g/dl PRL: 7.06 ng/ml

Lab tests
Urine output (ml) 980 680 USG 1.000 1.001

Fluid balance/24 h: - fluid intake: 9,5 L - urine output: 10.3 L

580
760 830 630 710 510

1000
1.000 1.000 1.000 1.000 1.000

1100
880 650 1100 910

1.000
1.000 1.000 1.000 1.000

WATER DEPRIVATION TEST

Start at 7:00 am:
Time (hour) Weight (kg) Urine output (ml) 460 220 200 250 200 140 110 90 100 USG

BP 115/80 mmHg, HR: 72 bpm, Body weight: 76 kg

07:00 08:00 09:00 10:00 11:00 12:00 13:00 14:00 15:00

76 75.6 75.3 75 74.7 74,4 74.3 74 73.5

1.000 1.002 1.000 1.000 1.000 1.000 1.000 1.000 1.000

(3% : 73,72 kg)

Plasma osmolality: at 7:00 am 312 mOsm/l

at 15: 00 pm 322 mOsm/l

DESMOPRESSIN solution, 2 drops intranasal (20 g) 230 140 1.020 1.030

180

1.025

Is there any imaging method needed ? Which one?

Paraclinical examination
Thyroid ultrasound:
Right lobe: 16/17.5/40 mm, volume 5.8 ml, with a posterocaudal nodule hypoechoic 9,5 x 21.5 mm, with hypervascularization Left lobe 12.5/ 18.4/ 39.5 mm, volume 4,87 ml. Istm: 4 x 7 mm, inhomogeneous structure without nodular formations

Paraclinical examination
Sestamibi with 99mTc Parathyroid Scintigraphy :
Parathyroid adenoma in the lower pole of the right lobe (~20/10mm), with high metabolic activity.

Paraclinical examination
Cranian MRI focused on hypothalamic-pituitary system

- a lesion about 2,5 mm in diameter, slightly hypointense compared to normal pituitary tissue, located in the left lob of the pituitary gland.

Other investigations necessary:

DEXA distal one-third of the nondomiant radius:
Radius 1/3 distal - T score =-1.2

Abdominal US - normal aspect Abdominal CT scan scheduled Ophthalmologic evaluation normal

Final diagnosis
o Central Diabetes Insipidus o Pituitary Microadenoma o Primary hyperparathyroidism o Parathyroid adenoma o Multiple endocrine neoplasia MEN 1 ?

Differential diagnosis
Other causes of polyuria - polydipsia syndrome :
- Diabetes mellitus - Nephrogenic DI - Primary polydipsia

Other causes of hypercalcemia:

Hypercalcemia of malignancy: nonmetastatic solid tumors, adult T-cell leukemia, lymphoma, multiple myeloma) Endocrine disorders: hyprthyroidism, acromegaly, adrenal insufficiency, pheocromocytoma Drug related: vitamin D intoxication, excessive vitamin A, thiazide diuretics, lithium, teriparatide immobilization

Secondary Hyperparatiroidism- causes: - Renal failure, decreased calcium intake, calcium malabsortion- vitamin D
deficiency, bariatric surgery, celiac disease; loop diuretics.

Treatment and monitoring

Desmopressin Minirin Melt 60 g 3 x 1 tb/zi Fluid balance/24 h under treatment : fluid intake: 2 L and urine output: 1.9 L Treatment of PHPT: minimally invasive parathyroidectomy surgery Histopathological result: parathyroid adenoma

PTH after surgery: 40,69 pg/ml (15 - 65 pg/ml)

http://surgery.med.umich.edu/general/endocrin e/patient/conditions/parathyroid/minimally_inv asive_parathyroid_surgery.shtml