A Fatal Case of Intraparenchymal Hemorrhage Masquerading as Central Diabetes Insipidus

Abstract

This is 32-year-old women presented to us on postpartum day 10 with severe covid-19 pneumonia. Hercomplaints were dyspnea and headache which she described as, frontally located, 8/10 in intensity, non-radiating and not associated with any posture. She had no prior history of migraines. She was afebrile, tachycardiac and hypoxic on exam. Physical examination was unremarkable. Patient failed trial of non-invasive ventilation following which she was intubated. CT head on admission was unremarkable.For COVID 19 ARDS, she was started on dexamethasone, tocilizumab, paralysis was achieved withcisatracurium and prone protocol was followed for refractory hypoxia. Patient was placed on DVTprophylaxis with heparin. Her pneumonia and oxygenation improved. However, on hospital day 8, herlab results were suspicious of Diabetes insipidus (DI). Her serum sodium was 152mEq/L with serumosmolarity of 360 and polyuria (more than 2L of urine in one hour). A full neurological examinationcould not be obtained as she was paralyzed, however, pupils were equal in size and reactive to light. With high clinical suspicions of diabetes insipidus she received a one-time dose of 16mcg of DDAVP andMRI of pituitary gland was ordered to delineate etiology. Subsequent improvement in polyuria wasnoted. Despite DDAVP her serum sodium continued to worsen. We continued to monitor serumsodium levels every four hours. Her serum sodium levels remained labile with a precipitous drop notedfrom 174mEq/L to 152mEq/L. Review of Pituitary MRI revealed multiple intraparenchymal hemorrhageson bilateral frontal lobes along with trans tentorial and cerebellar tonsillar herniation. Subsequently, patient underwent a brain death exam and declared brain dead. We suspect the development of intracranial hemorrhage in our patient was secondary to covid-19. Onliterature review, an incidence of 0.2% in covid-19 patients with a mortality of 48% is reported. In ourpatient, inability to perform a full neurological exam due to paralysis limited early recognition andintervention. This case highlights the need for increased awareness in patients with features of central diabetesinsipidus and the urgency to obtain CT head immediately after a diagnosis has been established. Promptconsideration of neuroimaging should be made when features of central diabetes mellitus are noted with limited neurological exam.