Hyponatraemia associated rhabdomyolysis following water intoxication

RHABDOMYOLYSIS SECONDARY TO RAPID CORRECTION OF HYPONATREMIA IN A PATIENT WITH PSYHCOGENIC POLYDIPSIA

Patients with chronic schizophrenia and psychosis are more prone to develop hyponatremia. Hyponatremia could be due to medications e.g. antidepressants/antipsychotics or secondary to psychogenic polydipsia. They often present with altered consciousness, seizures and falls. Rapid correction of hyponatremia in patients with psychogenic polydipsia has been associated to cause rhabdomyolysis, an under-recognized yet serious condition which if left untreated can result in various complications e.g. acute kidney injury, electrolyte abnormalities. We report a case of young patient who had background illness of schizophrenia and presented to department with severe hyponatremia secondary to psychogenic polydipsia and was eventually diagnosed as case of rhabdomyolysis due to rapid correction of hyponatremia. Objective of case report is to highlight the correct diagnosis of underlying cause of hyponatremia and challenges associated with managing rhabdomyolysis with IV fluids that can result in worsening of hyponatremia, hence emphasizing the importance of close monitoring of sodium levels and measurement of creatine kinase in any patient who presents with severe hyponatremia, particularly in the presence of other risk factors for rhabdomyolysis and consideration of careful fluid administration strategies in relation to the relative onset and risk of over-correcting hyponatremia.

Clinical characteristics and outcomes of hyponatraemia associated with oral water intake in adults: a systematic review

INTRODUCTION

Excessive water intake is rarely associated with life-threatening hyponatraemia. The aim of this study was to determine the clinical characteristics and outcomes of hyponatraemia associated with excess water intake.

METHODS

This review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies (case reports, observational or interventional studies) reporting excess water intake and hyponatraemia in adults (1946-2019) were included.

RESULTS

A total of 2970 articles were identified and 177 were included (88.7% case reports), consisting of 590 patients. The mean age was 46±16 years (95% CI 44 to 48 years), 47% female, 52% had a chronic psychiatric disorder and 31% had no underlying condition. The median volume of water consumed and serum sodium at presentation was 8 L/day (95% CI 8.9 to 12.2 L/day) and 118 mmol/L (95% CI 116 to 118 mmol/L), respectively. The motivator for increased water consumption was psychogenic polydipsia (55%); iatrogenic (13%); exercise (12%); habitual/dipsogenic polydipsia (7%) and other reasons (13%). The clinical features on presentation were severe in 53% (seizures, coma); moderate in 35% (confusion, vomiting, agitation) and mild in 5% (dizziness, lethargy, cognitive deficit) and not reported in 5% of studies. Treatment was supportive in 41% of studies (fluid restriction, treatment of the underlying cause, emergency care), and isotonic and hypertonic saline was used in 18% and 28% of cases, respectively. Treatment-related complications included osmotic demyelination (3%) and rhabdomyolysis (7%), and death occurred in 13% of cases.

CONCLUSION

Water intoxication is associated with significant morbidity and mortality and requires daily intake to substantially exceed population-based recommendations. The limitations of this analysis are the low quality and high risk of bias of the included studies.

PROSPERO REGISTRATION NUMBER

A pre-existing protocol in the international prospective register of systematic reviews was updated to incorporate any new amendments and reregistered at http://www.crd.york.ac.uk/PROSPERO (registration no. CRD42019129809).

A Sudden Fluctuation in Creatinine Kinase: Water Intoxication and Rhabdomyolysis

Water intoxication often causes hyponatremia. Acute hyponatremia and its rapid correction have been reported to cause rhabdomyolysis. However, little is known about the clinical course of water-intoxication-related rhabdomyolysis. We report a case of self-induced water intoxication resulting in rhabdomyolysis, in which serum creatinine kinase surged rapidly. The appropriate selection of fluid therapy was difficult because of the differences in the standard treatments for each complication. Water restriction is used to treat water intoxication, while the opposite, fluid resuscitation, is used to treat rhabdomyolysis. Close monitoring of serum creatinine kinase was useful in determining fluid management in such a situation.

Relationship between polydipsia and antipsychotics: A systematic review of clinical studies and case reports

OBJECTIVE

This systematic review aimed to elucidate the relationship between polydipsia and antipsychotics.

METHODS

We systematically searched MEDLINE, Embase, and PsycINFO, and included clinical studies and case reports on polydipsia induced or improved by antipsychotics.

RESULTS

We identified 61 articles: 1 double-blind randomized controlled trial (RCT), 4 single-arm trials, 1 cross-sectional study, 3 case series, and 52 case reports. The double-blind RCT demonstrated no significant difference in improvement in polydipsia between olanzapine and haloperidol. Two single-arm trials showed that polydipsia improved during clozapine treatment, whereas the other 2 showed that risperidone did not improve polydipsia. The cross-sectional study showed the prevalence of hyponatremia with first-generation antipsychotics (FGAs: 26.1%) and second-generation antipsychotics (SGAs: 4.9%). Two case series reported that clozapine improved polydipsia; the other one indicated that patients with polydipsia who were treated with FGAs had schizophrenia (70.4%) and mental retardation (25.9%). Of 90 cases in the case reports, 67 (75.3%) were diagnosed with schizophrenia. Of 83 cases in which antipsychotic treatment started before the onset of polydipsia, 75 (90.3%) received FGAs, particularly haloperidol (n = 24, 28.9%), and 11 (13.3%) received risperidone. Among 40 cases in which polydipsia was improved following antipsychotic treatment, 36 (90.0%) received SGAs, primarily clozapine (n = 14, 35.0%).

CONCLUSIONS

Although the causal relationship between polydipsia and antipsychotics remains unclear because of the paucity of high-quality studies, antipsychotics with high affinity to dopamine D₂ receptors may be associated with an increased risk of polydipsia while clozapine may be effective for treating polydipsia.

A compulsive act of excess water intake leading to hyponatraemia and rhabdomyolysis: a case report

Background

Primary polydipsia is commonly seen in patients with psychiatric illnesses. Excess water intake is also seen in patient with anorexia and anticholinergic medications. We report a patient who had hyponatraemia and rhabdomyolysis after consuming excess water for ureteric calculus.

Case presentation

A healthy middle-aged male presented with an episode of generalized tonic-clonic seizure and reduced level of consciousness preceded by consumption of excess water. He was recently diagnosed to have a ureteric calculus and was advised to consume plenty of water. On examination, he was disoriented in place, person and time. Except for the generalized diminished reflexes, other neurological and systemic examinations were normal. He had severe hyponatraemia, mild hypokalaemia and myoglobulinuria. His serum creatinine phosphokinase and aspartate aminotransferase were markedly elevated. The diagnosis of rhabdomyolysis in the setting of acute water intoxication was made. Optimum fluid and electrolyte management achieved a dramatic recovery of consciousness, hyponatraemia and rhabdomyolysis.

Discussion

The patient has had excess water intake due to a compulsive act in the background fear of ureteric calculus. Such act could lead to severe hyponatraemia and rhabdomyolysis. Therefore, future similar acts could be prevented by proper medical advice. Further, emergency physicians should be vigilant for rhabdomyolysis in patients with hyponatraemia or hypokalaemia.

Association between rapid serum sodium correction and rhabdomyolysis in water intoxication: a retrospective cohort study

Background

Patients with water intoxication may develop rhabdomyolysis. Existing studies suggest a relationship between the serum sodium correction rate and rhabdomyolysis. The aim of the present study was to determine the association between the sodium correction rate and rhabdomyolysis in patients with water intoxication.

Methods

Medical records from all cases of water intoxication presenting to the emergency department and admitted to a single tertiary emergency hospital between September 2012 and August 2016 were examined retrospectively. Serum sodium correction rate was defined as the difference in serum sodium levels at admission and approximately 24 h after admission, divided by time. The primary outcome was rhabdomyolysis, defined as peak creatine kinase level ≥ 1500 IU/L. Logistic regression analysis was used to calculate the adjusted odds ratio of the serum sodium correction rate controlling for age, sex, convulsion, lying down for >8 h before admission to the emergency department, and serum sodium level on admission.

Results

A total of 56 cases of water intoxication were included in the study. The median serum sodium correction rate was 1.02 mEq/L/h, and 32 patients (62.5%) had rhabdomyolysis. Logistic regression analysis showed that serum sodium correction rate was an independent risk factor of rhabdomyolysis (adjusted odds ratio, 1.53 per 0.1 mEq/L/h; 95% confidence interval, 1.18–1.97).

Conclusions

Rapid correction of serum sodium was associated with rhabdomyolysis in patients with water intoxication. Therefore, strict control of serum sodium levels might be needed in such patients.

Hyponatraemia-induced rhabdomyolysis complicated by anuric acute kidney injury: a renal replacement conundrum

Hyponatraemia-induced rhabdomyolysis is a rare, but reported phenomenon, particularly in patients with chronic schizophrenia on depot antipsychotics prone to psychogenic polydipsia. To the best of our knowledge, there are no reported cases of hyponatraemia-induced rhabdomyolysis complicated by oligo-anuric acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). The initiation of CRRT is complicated in severe hyponatraemia, predominantly due to the need to avoid rapid changes in tonicity associated with rapid changes in sodium. We report a case of severe hyponatraemia (104 mmol/L) complicated by oligo-anuric rhabdomyolysis-induced AKI and our management of the renal prescription.

Exertional rhabdomyolysis: physiological response or manifestation of an underlying myopathy?

Exertional rhabdomyolysis is characterised by muscle breakdown associated with strenuous exercise or normal exercise under extreme circumstances. Key features are severe muscle pain and sudden transient elevation of serum creatine kinase (CK) levels with or without associated myoglobinuria. Mild cases may remain unnoticed or undiagnosed. Exertional rhabdomyolysis is well described among athletes and military personnel, but may occur in anybody exposed to unaccustomed exercise. In contrast, exertional rhabdomyolysis may be the first manifestation of a genetic muscle disease that lowers the exercise threshold for developing muscle breakdown. Repeated episodes of exertional rhabdomyolysis should raise the suspicion of such an underlying disorder, in particular in individuals in whom the severity of the rhabdomyolysis episodes exceeds the expected response to the exercise performed. The present review aims to provide a practical guideline for the acute management and postepisode counselling of patients with exertional rhabdomyolysis, with a particular emphasis on when to suspect an underlying genetic disorder. The pathophysiology and its clinical features are reviewed, emphasising four main stepwise approaches: (1) the clinical significance of an acute episode, (2) risks of renal impairment, (3) clinical indicators of an underlying genetic disorders and (4) when and how to recommence sport activity following an acute episode of rhabdomyolysis. Genetic backgrounds that appear to be associated with both enhanced athletic performance and increased rhabdomyolysis risk are briefly reviewed.

Recurrent rhabdomyolysis secondary to hyponatremia in a patient with primary psychogenic polydipsia

Rhabdomyolysis is characterized by the destruction of skeletal muscle tissue, and its main causes are trauma, toxic substances and electrolyte disturbances. Among the latter is hyponatremia-induced rhabdomyolysis, a rare condition that occurs mainly in patients with psychogenic polydipsia. Psycogenic polydipsia mostly affects patients with schizophrenia, coursing with hyponatremia in almost 25% of the cases. It is also in this context that rhabdomyolysis secondary to hyponatremia occurs most often. In this article, the case of a 49-year-old male with a history of schizophrenia, medicated with clozapine, and brought to the emergency room in a state of coma and seizures is described. Severe hypoosmolar hyponatremia with cerebral edema was found on a computed tomography examination, and a subsequent diagnosis of hyponatremia secondary to psychogenic polydipsia was made. Hyponatremia correction therapy was started, and the patient was admitted to the intensive care unit. After the hyponatremia correction, the patient presented with analytical worsening, showing marked rhabdomyolysis with a creatine phosphokinase level of 44.058UI/L on day 3 of hospitalization. The condition showed a subsequent progressive improvement with therapy, with no occurrence of kidney damage. This case stresses the need for monitoring rhabdomyolysis markers in severe hyponatremia, illustrating the condition of rhabdomyolysis secondary to hyponatremia induced by psychogenic polydipsia, which should be considered in patients undergoing treatment with neuroleptics.