Central Diabetes Insipidus in the Background of Lithium Use: Consider Central Causes Despite Nephrogenic as the Most Common

Abstract

BACKGROUND Nephrogenic diabetes insipidus is a well-known adverse effect of lithium use. Albeit rare, there have also been documented cases of central diabetes insipidus (CDI) associated with lithium use. CASE REPORT A 31-year-old woman with a past medical history of bipolar disorder, managed with lithium 300 mg by mouth every day for 3 years, was assessed for a 1-year history of polyuria with accompanying polydipsia. During her initial hospital stay, her estimated urine output was more than 4 L per day. Initial labs showed elevated serum sodium (149 mmol/L; reference range 135-145), elevated serum osmolality (304 mOsm/kg; reference range 275-295), urine osmolality of 99 mOsm/kg (reference range 50-1200), and urine specific gravity (1.005; reference range 1.005-1.030). Lithium was at a subtherapeutic level of 0.05 mEq/L (reference range 0.6-1.2). Magnetic resonance imaging of the brain revealed no abnormalities of the pituitary gland. Two different occasions of desmopressin administration resulted in >50% increase in urine osmolality, confirming the diagnosis of CDI. Common causes of CDI, including trauma, tumors, and familial CDI, were ruled out and chronic lithium use was determined as the most probable cause for the patient's CDI. CONCLUSIONS CDI in the background of chronic lithium use is rarely reported. We present this case to consider CDI as a differential diagnosis when evaluating polyuria and hypernatremia in patients with long-term lithium use. These presentations warrant the consideration of both types of diabetes insipidus in the differential diagnoses.

Figure 1.

MRI of T1-weighted sagittal view of the brain showing normal pituitary gland.

Figure 2.

(A) Daily measurement of sodium concentration throughout the patient’s hospitalization. On Day 3, an infusion of Dextrose 5% was given as needed. On Day 8, Desmopressin trial 1 (4 µg DDAVP) was administered subcutaneously (SC), with additional doses of desmopressin (DDAVP) administered on an as needed basis. On Day 17, Desmopressin trial 2 (1 µg DDAVP) was given after an overnight water deprivation test, with further daily doses given as needed. (B) Daily measurement of urine output volume throughout the patient’s hospitalization. As needed DDAVP injections were given: 4 µg on Day 9, 4 µg on Day 10, 4 µg on Day 14, and 1 µg on Day 18.