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Cervantes G, Amaya J, Zarandi PA, Wilson D, Shori SK. Cerebral Salt Wasting Syndrome in the Setting of Hypovolemic Isotonic Hyponatremia: A Case Report. Cureus 2023; 15:e49928. [PMID: 38179389 PMCID: PMC10764298 DOI: 10.7759/cureus.49928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024] Open
Abstract
Cerebral salt wasting syndrome (CSWS) is a condition characterized as the loss of sodium secondarily due to an intracranial process, commonly following the neurosurgical resection of mass lesions. This condition leads to a hypovolemic hypotonic hyponatremia. The identification of this syndrome is often mistaken for syndrome of inappropriate anti-diuretic hormone (SIADH). The treatment for both conditions is vastly different. Given the risk of mortality when balancing sensitivities in hyponatremia and its commonality in clinical scenarios, a distinction is crucial. In this case report, we discuss a patient who presented with CSWS following the surgical resection of a pituitary adenoma. She subsequently developed hypernatremia, treated with DDAVP for the suspicion of diabetes insipidus. Once this was discontinued, she further presented with worsening hyponatremia. This hyponatremia persisted even after the discontinuation of DDAVP, with no significant intervention leading to hypovolemic isotonic hyponatremia, supporting a diagnosis of CSWS. Our findings stress the importance of the proper identification of hyponatremia with guided treatment following neurosurgical intervention and give physicians an insight into the anomalies of hyponatremia that should be further discussed.
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Affiliation(s)
- Gerik Cervantes
- Medicine, Anne Burnett School of Medicine, Texas Christian University, Fort Worth, USA
| | - Joshua Amaya
- Internal Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, USA
| | - Pardis A Zarandi
- Internal Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, USA
| | - Diana Wilson
- Neurosurgery, Baylor Scott and White All Saints Medical Center, Fort Worth, USA
| | - Sandeep K Shori
- Graduate Medical Education, Baylor Scott and White All Saints Medical Center, Fort Worth, USA
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Muacevic A, Adler JR, Sawaya A, Pensiero AL. Severe Hyponatremia in the Setting of COVID-19-Associated Syndrome of Inappropriate Antidiuretic Hormone: A Case Report. Cureus 2023; 15:e33330. [PMID: 36751173 PMCID: PMC9897715 DOI: 10.7759/cureus.33330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 01/05/2023] Open
Abstract
The COVID-19 pandemic has resulted in significant worldwide morbidity and mortality. One of the less studied clinical manifestations is Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) associated with COVID-19 pneumonia. We present a single case of COVID-19 pneumonia-associated SIADH in a 71-year-old male with a history of alcohol use disorder. This case highlights the importance of full diagnostic workup of the underlying cause of hyponatremia to avoid significant morbidity.
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Yossef K, Naidoo SF, Lai W, Levaka Veera RR. Early Detection of Immune-Mediated Hypophysitis With Use of Checkpoint Inhibitor Immunotherapy. Cureus 2022; 14:e24291. [PMID: 35602802 PMCID: PMC9119666 DOI: 10.7759/cureus.24291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 11/05/2022] Open
Abstract
Hypophysitis is the inflammation of the pituitary gland with varying effects on hormone function that may be present secondary to the use of certain medications, infections, systemic inflammatory disorders, and other etiologies. Immunotherapy-related hypophysitis is a rare phenomenon. However, it represents an indication of treatment interruption. We report a 60-year-old female with renal clear cell carcinoma on Nivolumab and Ipilimumab (NIVO/IPI) intravenously (IV). After the second cycle of therapy, the patient reported a fall, with associated lightheadedness, dizziness, nausea, vomiting, and hot flashes. The patient's symptoms and history were concerning for hypophysitis, so early treatment and cessation of the checkpoint inhibitors led to the patient's clinical improvement.
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Affiliation(s)
| | - Shiva F Naidoo
- Internal Medicine, Geisinger Health System, Wilkes-Barre, USA
| | - William Lai
- Internal Medicine, Geisinger Health System, Wilkes-Barre, USA
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Elmahal M, Lohana P, Anvekar P, Ali SR, A Baath Allah S. Syndrome of Inappropriate Antidiuretic Hormone Secretion-Induced Encephalopathy in a Patient With COVID-19. Cureus 2021; 13:e16671. [PMID: 34513345 PMCID: PMC8412218 DOI: 10.7759/cureus.16671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 11/23/2022] Open
Abstract
Various electrolyte imbalances have been documented in coronavirus disease 2019 (COVID-19) patients who progress to severe acute respiratory syndrome coronavirus-2 infection. Patients with co-morbidities like diabetes, hypertension, obesity, ischemic heart disease, chronic kidney disease, and chronic obstructive pulmonary disease are more vulnerable to developing complications in the form of electrolyte disturbance. We report a case of acute severe hyponatremia in a middle-aged man who was admitted to the hospital with viral pneumonia due to a coronavirus-2 infection. A dramatic drop of plasma sodium was preceded by gastrointestinal symptoms and followed by encephalopathy. On clinical assessment his plasma sodium was found to be critically low, i.e. 105 mmol/L. His chest x-ray showed minimal pleural effusion. The patient was managed in the ICU and his serum sodium was normalized gradually with partial but rapid correction of this severe hyponatremia with hypertonic sodium chloride and followed by fluid restriction.
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Affiliation(s)
| | - Petras Lohana
- Internal Medicine, Liaquat University of Medical and Health Sciences Hospital, Karachi, PAK
| | - Priyanka Anvekar
- Internal Medicine, Mahatma Gandhi Mission (MGM) Medical College and Hospital, Mumbai, IND
| | - Syed R Ali
- Internal Medicine, Dow University of Health Sciences, Civil Hospital Karachi, Karachi, PAK
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Illg Z, Dabaja A, Garcia L, Adams N, Gunaga S. Neurogenic Stunned Myocardium Following an Attempt to Pass a Drug Test. Cureus 2021; 13:e18318. [PMID: 34722083 PMCID: PMC8549404 DOI: 10.7759/cureus.18318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2021] [Indexed: 11/06/2022] Open
Abstract
Ingestion of a large volume of free water or other hypotonic solution can cause acute hyponatremia, leading to multiorgan dysfunction. Individuals may attempt to generate a false-negative urine drug screen through increased free water consumption leading to acute hyponatremia requiring emergency medical care. We present the case of a 19-year-old male who presented to a community emergency department for altered mental status after an attempt to generate a false-negative urine drug screen. He ingested a large volume of free water and multiple detoxification solutions, causing acute hyponatremia with resultant cerebral edema and neurogenic stunned myocardium. He required extracorporeal membrane oxygenation therapy with complete recovery of neurologic and cardiac function. Acute hyponatremia from excess free water consumption is a well-documented phenomenon that all emergency providers should be aware of. Prompt identification and management of acute hyponatremia are essential to prevent potentially severe, devastating sequelae, including cerebral edema and cardiopulmonary failure.In addition, extracorporeal membrane oxygenation may be considered in patients with cardiopulmonary failure in the setting of reversible cardiomyopathy, as evidenced in our case.
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Affiliation(s)
- Zachary Illg
- Emergency Medicine, Henry Ford Wyandotte, Wyandotte, USA
- Emergency Medicine, Emory University, Atlanta, USA
| | - Aya Dabaja
- Emergency Medicine, Henry Ford Wyandotte, Wyandotte, USA
| | - Laura Garcia
- Emergency Medicine, Henry Ford Wyandotte, Wyandotte, USA
- Emergency Medicine, Ascension Sacred Heart Pensacola, Pensacola, USA
| | - Nicole Adams
- Emergency Medicine, Henry Ford Wyandotte, Wyandotte, USA
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Pillutla V, Patel A, Koneru S, Ng KK, Ng MK. A Case Report of Severe Hyponatremia Secondary to Coronavirus Disease 2019 Viral Pneumonia. Cureus 2021; 13:e14077. [PMID: 33903839 PMCID: PMC8062316 DOI: 10.7759/cureus.14077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
As of December 2020, the coronavirus disease 2019 (COVID-19) pandemic has resulted in 82.2 million cases worldwide. We report the case of a 69-year-old South Asian female with a history of hypertension, hypothyroidism, meningiomatosis, and urinary incontinence who contracted COVID-19 and developed severe hyponatremia. She was initially medically managed with antibiotics, anti-parasitics, anti-coagulants, and steroids. After experiencing breathlessness, chest discomfort, high systolic blood pressure, and tachycardia, she was admitted and diagnosed with post-COVID pneumonia, and was conservatively treated with steroids. She showed improvement, and was discharged upon being declared hemodynamically stable. While the patient was at home, she experienced periods of breathlessness and acral edema. This case raises the question of the correlation between hyponatremia and COVID-19, especially in regards to symptomatic presentations, including altered mental status, headache, and nausea. As there are limited studies that show severe electrolyte disorders leading to mortality, more research is needed to understand hyponatremia in cases with COVID-19.
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Affiliation(s)
| | - Anooj Patel
- Plastic Surgery, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Sindhoora Koneru
- Department of Biomedical Sciences, Texas A&M University, College Station, USA
| | - Kenneth K Ng
- Anesthesiology, State University of New York Downstate Health Sciences University, Brooklyn, USA
| | - Mitchell K Ng
- Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, USA
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van Houte J, Bindels AJ, Houterman S, Dong PV, den Ouden M, de Bock NE, Verberkmoes NJ, Curvers J, Bouwman AR. Acute isotonic hyponatremia after single dose histidine-tryptophan-ketoglutarate cardioplegia: an observational study. Perfusion 2020; 36:440-446. [PMID: 32755277 DOI: 10.1177/0267659120946952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Histidine-tryptophan-ketoglutarate cardioplegia is used for prolonged myocardial protection in complex cardiac surgery. Administration leads to acute hyponatremia in a majority of patients, because of its low sodium concentration (15 mmol/L). However, histidine-tryptophan-ketoglutarate solution's osmolality is slightly hypertonic (310 mOsm/kg). Hypothesized was that acute isotonic hyponatremia will be induced, which does not need to be corrected with hypertonic saline. METHODS Cardiac surgery patients who received histidine-tryptophan-ketoglutarate cardioplegia were included in this prospective single center study. Serial blood samples were taken from each patient at five different time points: after induction of anesthesia (T1) and 10 minutes (T2), 6 hours (T3), 12 hours (T4), and 18 hours (T5) after administration of histidine-tryptophan-ketoglutarate cardioplegia, respectively. Blood samples were analyzed for sodium concentration, osmolality, and acid-base balance. RESULTS Twenty-five patients were included. Median blood sodium levels decreased from 140 [138-141] at T1 to 128 [125-130] mmol/L at T2 (p < 0.001). At T3, T4, and T5, median blood sodium concentrations were 136 [134-138], 139 [137-140], and 140 [137-142] mmol/L, respectively. Median osmolality was 289 [286-293] at T1 and increased to 296 [291-299] mOsm/kg (p < 0.001) at T2. At T3, T4, and T5, osmolality was 298 [292-302], 298 [294-304], and 300 [297-306] mOsm/kg, respectively. Median pH decreased from 7.38 [7.36-7.40] at T1 to 7.30 [7.27-7.32] at T2 (p < 0.001). CONCLUSION Administration of histidine-tryptophan-ketoglutarate cardioplegia during cardiac surgery leads to acute moderate to severe isotonic hyponatremia, which resolves spontaneously in the first 18 hours perioperatively. Correction with hypertonic saline is not necessary.
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Affiliation(s)
- Joris van Houte
- Department of Anaesthesiology, Catharina Hospital, Eindhoven, The Netherlands.,Department of Intensive Care, Catharina Hospital, Eindhoven, The Netherlands
| | - Alexander J Bindels
- Department of Intensive Care, Catharina Hospital, Eindhoven, The Netherlands
| | - Saskia Houterman
- Department of Research and Education, Catharina Hospital, Eindhoven, The Netherlands
| | - Phi Vu Dong
- Department of Anaesthesiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Monique den Ouden
- Department of Anaesthesiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Nina E de Bock
- Department of Extra Corporeal Circulation and Blood management, Catharina Hospital, Eindhoven, The Netherlands
| | - Niels J Verberkmoes
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Joyce Curvers
- Department of Clinical Chemistry, Catharina Hospital, Eindhoven, The Netherlands
| | - Arthur R Bouwman
- Department of Anaesthesiology, Catharina Hospital, Eindhoven, The Netherlands
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Fujiwara A, Nakahira J, Nakano S, Sawai T, Minami T. Efficacy of Goreisan in Preventing Transurethral Resection Syndrome in Transurethral Resection of the Prostate: A Randomized-Controlled Study. J Altern Complement Med 2020; 26:738-742. [PMID: 32609534 DOI: 10.1089/acm.2019.0269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objectives: Nonconductive irrigation fluids used during transurethral resection (TUR) of the prostate can cause fluid overload and dilutional hyponatremia. TUR syndrome is generally defined as serum sodium at or below 125 mmol/L with cardiovascular and neurologic symptoms. The aim of this study was to evaluate the effects of Goreisan, a traditional Japanese Kampo medicine, on serum sodium levels and the occurrence of TUR syndrome in patients undergoing TUR of the prostate. Design: This was a randomized-controlled trial. Settings/Location: This trial was conducted at the Osaka Medical College Hospital and Keneikai Sanko Hospital. Subjects: Fifty patients scheduled for TUR of the prostate were included. Interventions: Patients in the Goreisan group (n = 23) received 2.5 g Goreisan orally on the night before surgery and on the morning of surgery. The control group (n = 27) did not receive Goreisan. Surgical procedures, perioperative management, and patient monitoring were otherwise the same in both groups. Outcome Measures: The primary outcome was occurrence of TUR syndrome. The secondary outcome was serum sodium level. Results: Serum sodium remained above 125 mmol/L in all patients, so none of the patients met the criteria for TUR syndrome. However, the Goreisan group had significantly higher intraoperative sodium levels (p < 0.001) and significantly higher intraoperative (p = 0.008) and postoperative (p = 0.02) hemoglobin levels than the control group. Conclusions: These findings indicate that preoperative Goreisan administration can help maintain serum sodium levels in patients undergoing TUR of the prostate.
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Affiliation(s)
- Atsushi Fujiwara
- Department of Anesthesiology, Osaka Medical College, Osaka, Japan
| | - Junko Nakahira
- Department of Anesthesiology, Osaka Medical College, Osaka, Japan
| | - Shoko Nakano
- Department of Anesthesiology, Osaka Medical College, Osaka, Japan
| | - Toshiyuki Sawai
- Department of Anesthesiology, Osaka Medical College, Osaka, Japan
| | - Toshiaki Minami
- Department of Anesthesiology, Osaka Medical College, Osaka, Japan
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