ADDICTED to WATER
A woman spent nearly four decades assuming her unquenchable thirst is nothing more than a little quirk.
By: Lisa Sanders, M.D.
“Can I help you?” The indifferent voice crackled throgh the hospital intercom. “Please, I am so, so thirsty,” answered the woman in the bed. “1 feel awful, but I know I’d feel better if I just have a drink of water. ” Her mouth was so dry it hurt, and her head pounded painfully . She felt dizzy and sweaty.
“I’ll let your nurse know,” replied the voice.
It seemed to the woman that her life had always revolved around water. She was always thirsty, always drinking. When she went out she carried two or three water bottles with her . When she went to sleep, she needed two glasses of water at her bedside That morning she had come to the hospital for a C-section to dcliver a baby too big to get out any other way. Now the beautiful babv was sleeping and the mother was desperately thirsty. When the nurse appeared with a pitcher of water, the woman almost wept with relief.
The next morning, Dr. Heidi Chen, the OB-GYN intern, woke the patient early. The young doctor was worried, and it showed on her face. The patient had drunk an enormous amount of water in the hours following her C-section — well over three gallons. Her urine output had been just as remarkable. The doctor neded to figure out what was going on.
The patient sat up and rubbed her eves sleepily. She was 38 years old, perfectly healthy and, she told Chen, liked to drink a lot of water. Her friends had sometimes kidded her about her constant array of water bottles and her frequent trips to the bathroom, but she’d never thought much about it. Her mother-in-law had been concerned, though A few years earlier when the woman and her husband were visiting his mother something had gone wrong with their well, and they had loaded up on bottled drinking water . That night the woman went to bed with a gallon bottle. The next morning it was cmpty. The surprised, then worried look on her mother-in-law’s face when she saw how much the young woman had drunk scared her a little.
When she had told her regular doctor about her thirst, his first thought was that she might have diabetes . Increased thirst and hunger are common symptoms of this very common disease. She’d fasted and gone to the lab to haxe her blood sugar measured. It was normal.
He checked it again . Still normal . ~She’d also taken a glucose tolerance test and that too was normal. He had reassured her: It’s good to drink a lot of water.
By then she’d been tested dozens of times for diabetes. The tests were always real normal, and so eventually the patient decided that her crazy thirst might be strange but not serious.
But Chen thought it was serious. Was she urinating so much because she was drinking too much? If this was the case, the intern explained, the problem was a condition known as psychogenic polydipsia, an uncontrollable compulsion to drink, usually but not always due to mental illness. Or was she drinking so much to keep up with the fluid she was losing as urine? And if the latter, what was so wrong if it wasn’t diabetes mellitus?
Could she have a different form of diabetes? The word diabetes comes from the Greek word for ~‘siphon” because diabetics pass so much urine they are like siphons draining water. Diabetes mellitus is so named for the honey-like taste of a diabetic’s urine, sweetened by sugar the body cannot absorb — knowledge garnered through an antique diagnostic technique.
But there is another type of diabete s known as diabetes insipidus. In this rare disease, the kidneys can’t hold on to the water the body needs. The urine is insipid so diluted it looks, smells and tastes just like water . Pregnancy increases the risk of developing this unusual version of diabetes.
They had to figure this out, Chen explained. All the patient would have to do is not drink anything at all for four hours. If the urine remained diluted even when the patient couldn’t replace it. that would mean the problem was that her kidneys couldn’t reabsorb water and would indicate she had diabetes insipidus.
Four hours without water? Just thinking about the prospect made the patient feel the familiar panic she had whenever she found herself away from a ready source ot water. Fou r hours?
No way. She’d been like this most of her life, and there was no need to rush to figure this out — not if it meant going that long without drinking.
Later that morning, Chen asked Dr. Brian Rifkin, the kidney specialist on call, for help with this difficult diagnosis. After reviewing the woman’s chart, it was clear to the doctor that she did not have psychogenic polydipsia. Patients with this abnormal drive to drink take in far more water than they need, making their blood as well as their urine diluted.
This patient was, instead, a little dehydrated; her blood was more concentrated than normal. It appeared that she was drinking in order to replace the fluid she was losing in her excessive urine output. He believed she had diabetes insipidus. The question in his mind was why.
The body regulates fluid balance using a hormone called vasopressin.
When your body needs to hold on to fluid — perhaps because you aren’t drinking enough the pituitary gland in the brain secretes this hormone, which then travels through the body to the kidneys and tells them to hold on to water. When this highly effective, finely tuned biological system breaks down, it’s important to figure out why . It’s usually because of an injury to the pituitary —an injury due to trauma or surgery or sometimes to a tumor.
Rifkin introduced himself to the patient and her husband. This was most likely diabetes insipidus. he explained. It’s not a serious condition unless you find yourself in circumstances where you can’t drink water. If you were, say, in a car accident or if you needed surgery, you could become extremely dehydrated. You could even die. One blood test will confirm the diagnosis. If your brain isn’t making the needed hormone, you can replace it easily.
She agreed to the blood test---- anything else would have to wait.
When the results came back, the diagnosis was clear. Her brain was making no vasopressin at all. She couldn’t recall a head injury and certainly hadn’t had brain surgery. Finally an M.R.I. ruled out the presence of a tumor. That left what’s called idiopathic diabetes insipidus where the cause isn’t known.
She started on a synthetic vasopressin, a nose spray that she took once a day. And immediately everything was different.
“I can’t tell you how much it’s changed my life,” she told me recently. Not long after she started taking the medication, she went to the mall with her child. Once there, she realized that she hadn’t brought any water bottles. “Initially I panicked,” she said. “Then I remembered. I didn’t need it.” And she spent an entire hour in the mall without drinking and without even a single trip to the bathroom. “It was a first for me.”
How could the woman have gone her whole entire life without her ailment being diagnosed? How come no one had figured it out sooner? I thought I understood how this could happen. Presented with a patient with excessive thirst and urination, the odds are overwhelming that this will be diabetes mellitus. A no-brainer so much so that when that diagnosis turns out to be wrong, it’s easier to assume that your patient is actually fine, perhaps overly sensititve to her thirst, than to ask the most important question in medicine: Could this really be something else? “I guess they just never thought of the other diabetes,” the patient told me thoughtfully. Then she added with a laugh , “But now that I know, I’m still not planning any trips to the Mojave Desert.”
If you have a question or solved case to share with Dr. Sanders, you can e-mail to her at: Lsanders@pol.net
The New York Times Magazine
October 14, 2007 Section 6. (pgs. 42-44)
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