Resolution of diabetes insipidus following Sodium cromoglicate for mast cell disorder
Falinska A, Todd JF. Imperial Centre For Endocrinology, Imperial College Healthcare NHS Trust, Hammersmith Hospital.
Central diabetes insipidus (DI) is characterised by polyuria, polydipsia, and
nocturia and is due to vasopressin deficiency. The prognosis depends on the underlying aetiology but in the majority of cases, it is a lifelong condition.
This is a case of 26-year-old male who presented with 5 year history of extreme fatigue, malaise, lethargy, dizziness and pre-syncopal episodes. He arrived for the appointment with a big 5L bottle of water and admitted to polydipsia, polyuria and nocturia for several years. Previously he had successful ablation for re-entrant tachycardia/atrial fibrillation and neurological causes of his episodes were excluded. He was diagnosed with postural orthostatic tachycardia syndrome (POTS). Water deprivation test confirmed cranial diabetes insipidus and his symptoms improved following initiation of DDAVP. His inflammatory markers were normal and his MRI pituitary scan and anterior pituitary function tests were both normal. Following being diagnosed with DI, he developed severe skin reaction with intermittent urticaria to diary and soya probiotic drinks, dogs, cats and polyester. He was diagnosed with mast cell activation disorder and started on Sodium cromoglicate orally. Within a few weeks of starting this treatment he stopped taking DDAVP of his own volition, as he felt unwell. Without DDAVP he was only drinking 1.5 litres a day with no nocturia. His electrolytes remained normal and repeated water deprivation test showed complete resolution of diabetes insipidus.
We were unable to identify any recognised cause of his DI such as brain tumours, trauma, neurosurgery, granulomas - sarcoidosis, histiocytosis, infection, hemochromatosis and infundibulo-neurohypophysitis. Above conditions can be associated with infiltration of hypothalamus and /or posterior pituitary. As this patient was diagnosed with mast cell activation disorder, it is possible that his mastocytes infiltrated his hypothalamus causing DI. . Sodium cromoglicate is a mast cell stabiliser and prevents release of their chemical contents. It appears that his diabetes insipidus has completely resolved following initiation of this agent suggesting that mastocytes played crucial role in pathophysiology of DI in his case.