6 week old infant boy with polyuria. Matthew Wise, MD Med Peds Endo March 1, 2012
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1 6 week old infant boy with polyuria Matthew Wise, MD Med Peds Endo March 1, 2012
2 HPI 6 week old hispanic boy Full term, uncomplicated pregnancy Well until 3 weeks: irritability, difficulty breathing, poor feeding URI sx runny nose, cough Hospitalized x1wk sepsis evaluation negative; CXR suggestive of bilateral pneumonia Received empiric abx: azithromycin + clindamycin
3 Re Admission 1 week after discharge Increased work of breathing, persistent cough, difficulty feeding CPAP; CXR with bilateral infiltrates: CT HD#4 BAL and intubation IV Abx: Azithro/Clinda Amphotericin B (conventional) HD#7: consult Endo for polyuria for prior 1 day (11.7 ml/kg/hr) and Na rise from 135 to 146
4 Medical/Surgical History PMH Pneumonia dx age 3wks Circumcision Birth Full term, vaginal delivery 7lbs 2oz Developmental Smile Tracking with eyes Allergies: NKDA Meds: Azithro Clinda Ampho B (conventional) Versed Morphine Albuterol Lasix x2 (HD#2, #5)
5 Family and Social History Family Negative for diabetes or pituitary issues Negative for renal diseases No early neonatal death Social Living with mother in apartment with mother s friend Father not involved Strong support from family s church
6 Physical Exam Birth Wt 3.2 kg (27%) 36.5 C, HR 157, BP 72/42, RR 44, Wt 3.9kg (5%), Lgth 54.4cm (20%) Gen: Sleeping/sedated Head/Face: no dysmorphia, PERRLA, anterior fontanelle flat Nose: intubated, NG tube Mouth: mucosa moist Neck: no thyromegaly, no acanthosis Resp: +crackles bilaterally CV: RRR no m/r/g Abd: Soft, scaphoid, non tender, no masses GU: Normal male genitalia, testes descended, circ Ext: cap refill <2sec Neuro: no focal neurologic signs Derm: pustular/papular rash on face
7 Fluid and Sodium Data consult Hosp Day #1 #2 #3 #4 #5 #6 #7 Na Ins Outs Net ml/kg/hr Urine SG Sosm Uosm Una Meds Lasix Ampho B Lasix
8 Other Labs AVP level sent same day pending (later came back undetectable) (concurrent Na by blood gas: 136)
9 Assessment and Recs Diabetes Insipidus (central vs. nephrogenic) partial Medication induced? Amphotericin B Aspergillus related? Congenital? AVP R or AQP mutations (nephrogenic) Prepro AVP or mitochond 4p16 deletion (central) Replace free water losses with hypotonic fluid Change Ampho B to alternative formulation Continue to monitor Na/I&O s daily DDAVP trial or Diuretics/NSAID if recurrence/persistence MRI of brain/pit (PICU team already pursuing)
10 MRI of Brain/Pituitary Normal
11 consult Fluid and Sodium Data Hosp Day #6 #7 #8 #9 #10 #11 #12 #13 #14 #15 Na Ins Outs Net ml/kg/hr Urine SG Sosm Uosm Una Meds Ampho B conventional Ampho B liposomal Lasix Lasix Lasix
12 Clinical Questions 1) How do you define polyuria in children? 2) What is the mechanism of amphotericin B causing nephrogenic DI is there a role for changing the formulation? 3) Can Aspergillus cause DI and/or pituitary disease?
13 Polyuria in Children Polyuria urine output >5 ml/kg/hour (Saborio Costa Rica,PedsinRev 2000) >2 L/m 2 /day (Bichet Montreal, Uptodate 2012) Our patient on HD#6: urine output 1090 ml = 11.6 ml/kg/hr 0.24m 2 = 4.5 L/m 2 /day
14 Drug induced DI American Journal of Kidney Diseases, Vol 45, No 4 (April), 2005: pp
15 Amphotericin B and DI Incidence of NDI with Ampho B uncommon Case reports Mechanism(s) not fully described prostaglandin excess degrade AQP channels hypokalemia defective adenylate cyclase 1 report of resolution with change to liposomal form (Spath Schwalbe 1999) 3 reports of liposomal Ampho B causing NDI (Metzger 2009, Canada 2003, Araujo 1998) 2 reports lipid complex Ampho B causing DI (Metzger 2009, Hopp 2001)
16 Aspergillus and Pituitary Mass Iplikcioglu et al 2004
17 Return to Our patient Remains in PICU Extubated to CPAP, clinically improving Transitioning off ampho B to voriconazole No recurrence of polyuria or hypernatremia Probable immunodeficiency: (CGD) chronic granulomatous disease impairment in phagocyte oxidase mechanism
18 Take Home Polyuria in children is defined as urine ouput > 5 ml/kg/hr or >2 L/m 2 /day Amphotericin B is an uncommon, reversible cause of drug induced nephrogenic DI; changing formulation to liposomal/lipid complex may improve this, though DI also shown with these formulations Aspergillus is a rare cause of pituitary abscess
19 References Saborio P, Tipton GA, Chan JC. Diabetes Insipidus. Pediatr Rev. 2000;21: Spath Schwalbe et al. Successful use of liposomal amphotericin B in a case of amphotericin B induced nephrogenic diabetes insipidus. Clinical Infectious Diseases 1999;28: Hopp et al. Amphotericin B induced partial nephrogenic diabetes insipidus in a child 2001;16: Pinzer et al. Primary aspergillosis of the sphenoid sinus with pituitary invasion a rare differential diagnosis of sellar lesions. Acta Neurochirurgica 2006;148: Iplikcioglu AC et al. Aspergillus pituitary abscess. Acta Neurochirurgica 2004; 146:
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Case Presentation: Mr. S
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Incorporating Nutrition-Focused Physician Assessment into Malnutrition Diagnosis Robert DeChicco MS, RD, LD, CNSC Manager, Nutrition Support Team Center for Human Nutrition Cleveland Clinic Health System,
New Patient Information Form
New Patient Information Form Patient Identification Prenatal Alcohol & Drug Exposure Clinic FASD CLINIC Patient s OHIP N. Female Male Race Patient s Name Birth Date Age First Middle Last Patient s Address
Arcana Center for Integrative Medicine
Arcana Center for Integrative Medicine Patient s Name: Date of Birth: Reason for today s visit: Past Medical History Primary care physician: Date of last exam: (sick or well) Physician s Address: Office
Kristen Dillard, M.D. Endorama December 6, 2012
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W/ (2) (3) (4) (5) (5) (6) (6) CTA
Index Abdomen W/ and W/Out (2) Abdomen Pelvis W/Out (3) Abdomen Pelvis W/ (4) Pelvis W/ (5) Chest W/Out (5) Chest/Abdomen/Pelvis W/ (6) Chest W/ (6) CTA ( 7-8) Neuro (8-9) Musculoskeletal (10) Trauma (11)
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