VCOM Research Day Program Book 2023

Medical Resident Research Case Reports

22 Nephrogenic Diabetes Insipidus: A Case Review of Secondary Causes

Matthew Clem, DO; Emil Montano, DO; Vaneesha Patel, DO; Stephen Pillinger, DO; Alex Repko, DO Corresponding author: matthew.clem@lpnt.net

SOVAH Health Family Medicine Residency Program

and vitals were obtained, and she was determined to be septic. She received appropriate antibiotics and fluid resuscitation. The patient was admitted to the hospital and evaluated by neurology who ruled out seizure and intracranial pathology with MRI and EEG. Despite antibiotics, improvement of vitals, and adequate fluid resuscitation, her mental status did not improve. A rapid response was called due to concerns of seizure-like activity at which time she was given Ativan, which improved her agitation. Of note, her sodium levels would persistently be elevated despite appropriate fluid management for hypernatremia. A water depravation test was performed and showed no clinical change in urine concentrations. Following the water depravation test, a Desmopressin sensitivity test was performed and indicated complete Nephrogenic diabetes insipidus. Diagnosis: Complete nephrogenic diabetes insipidus, likely multifactorial from previous lithium use, acute kidney injury, dehydration, and polypharmacy. Treatment: Nephrology was consulted and recommended aggressive oral repletion of free water with low dose hydrochlorothiazide. Patient's

mental status continued to improve a few days after treatment. Her sodium levels continue to be monitored and began to normalize with treatment. Comment: After the patient's mental status improved, she was able to inform the medicine team that she had previously been on lithium, however she was on lithium multiple years prior. Therefore, it is unclear the exact etiology of the patient's nephrogenic diabetes insipidus and likely was multifactorial, with contributing factors including but not limited to, previous lithium use, acute kidney injury, dehydration, and polypharmacy. Conclusion: Though diabetes insipidus can be rare, early recognition from clinical signs and a good history is important to narrow down a broad differential and prevent adverse outcomes in patients.

Context: Nephrogenic diabetes insipidus (DI) is a condition that causes a decrease in urinary concentrating ability the results from resistance to the action of ADH. Various conditions can contribute to the development of nephrogenic DI, of which there are hereditary and secondary cause. Secondary causes include, but are not limited to, lithium toxicity, hypercalcemia, hypokalemia, kidney disease, drugs, and many other clinical conditions. Case Report: A 46-year-old Caucasian female presented to the emergency room via EMS for reported episode of syncope vs seizure from Center Virginia mental hospital. On the way to the ED, she threw herself from a traveling vehicle, sustaining multiple minor injuries. No further history could be elicited from the patient as she was combative and could not appropriately answer questions. CT head showed no acute intracranial findings. Right lower extremity x-ray showed no fracture or dislocation. D-dimer was elevated; CTA chest demonstrated no evidence of pulmonary embolism; however there was evidence of possible aspiration pneumonia. A DVT study was obtained, and patient was found to have bilateral occluding deep venous thrombi in her lower extremities. After initial blood work, imaging

39

2 0 2 3 R e s e a r c h R e c o g n i t i o n D a y