Case Report: Chorea as a Rare Manifestation of Secondary Adrenal Insufficiency

The word "chorea" comes from the Latin word "choreus," which means dancing movement. Chorea is defined as a hyperkinetic movement disorder characterized by uncontrolled, unintended, jerky, brief, irregular, random movements involving the limbs or facial muscles. Here, we discuss the case of a 48-year-old male with hypothyroidism for two years, which is well-controlled with medication. He presented with behavioral disturbances for the past seven months and choreiform movements affecting all four limbs, his tongue, and his face for the past six months. Investigations revealed hyponatremia and low serum osmolality. An MRI of the brain showed the empty sella sign. Further investigations revealed low levels of adrenocorticotropic hormone (ACTH), prolactin, and testosterone. Considering the diagnosis of chorea with euvolemic hyponatremia due to secondary adrenal insufficiency, the patient was started on tetrabenazine, trihexyphenidyl, oral hydrocortisone, and gradual correction of sodium level. The patient's condition improved during the hospital stay, and he continues to do well in routine follow-ups.

Isolated hypoaldosteronism is a cause of hypovolemic but not euvolemic hyponatremia

Introduction

Hypoaldosteronism is characterized by hyperkalemia, and/or hypovolemic hyponatremia (HH), often accompanied by metabolic acidosis. HH is typical of hypoaldosteronism, whereas euvolemic hyponatremia (EH) is not. The purpose of the current study is to describe the characteristics of hyponatremia in hypoaldosteronism and elucidate whether EH can be considered part of the disease's spectrum.

Methods

In a hypoaldosteronism cohort, we analyzed the factors associated with hyponatremia, comparing the characteristics of EH and HH and their associated factors. Correlation analyses of mineralocorticoid biomarkers, such as the transtubular potassium gradient (TTKG), the urinary Na+/K+ ratio (UNa+/UK+) with serum, and urinary electrolytes were performed in both types of hyponatremia.

Results

Of 112 hypoaldosteronism episodes, 77.7% were ≥65 years old, 44.6% were women, and 80 (71.4%) had hyponatremia. Hyponatremia was negatively associated with the presence of chronic kidney disease, and positively with a hypovolemic state, malnutrition, a prior history of hyponatremia, and glucocorticoid therapy. HH: 61/80 and EH: 19/80 episodes. HH was associated with an age ≥65 years and the use of diuretics, as well as factors related to an aldosterone deficit and/or mineralocorticoid resistance. In HH but not in EH, urinary potassium was correlated with the TTKG, and urinary sodium with both the TTKG and the UNa+/UK+.

Conclusion

Both HH and EH can be observed in hypoaldosteronism. However, only the former would be related to insufficient mineralocorticoid activity.

Significance statement

Isolated hypoaldosteronism is a poorly understood and underdiagnosed endocrinological disorder, classically recognized only when hyperkalemia is present. The development of hypovolemic hyponatremia, however, is also easily explained by the physiopathology of the disorder. The current study addresses the features of hyponatremia when found in the context of mineralocorticoid insufficiency, and confirms an association between hypovolemic hyponatremia and isolated hypoaldosteronism. Thus, the clinical spectrum of hypoaldosteronism is extended to include hypovolemic hyponatremia as a frequent manifestation of the disorder.

Atypical Clostridium difficile Infection in a Pregnant Patient: A Case Study on Non-Diarrheal Presentation and Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Complication

Clostridium difficile (C. difficile) is a Gram-positive, spore-producing bacterium that often leads to pseudomembranous colitis, typically manifesting as watery diarrhea. The risk factors for C. difficile infection (CDI) include exposure to broad-spectrum antibiotics, immunocompromised states, advanced age, usage of proton pump inhibitors (PPI), and comorbid conditions such as chronic kidney disease (CKD). This report details a case involving a 23-year-old pregnant woman who presented with symptoms of abdominal pain and constipation. She was diagnosed with a urinary tract infection (UTI) and treated with ceftriaxone. During her hospitalization, she was administered opioid pain relievers and underwent an intensive bowel regimen. Despite these measures, her constipation and abdominal discomfort persisted, and magnetic resonance imaging (MRI) of the abdomen revealed significant dilatation of the large bowel. The patient, discovered to have hyponatremia, underwent further evaluation. This revealed elevated urine osmolality and decreased blood plasma osmolality, indicative of a syndrome of inappropriate antidiuretic hormone secretion (SIADH). The patient received treatment with hypertonic saline. Later in her hospital stay, she tested positive for CDI through stool analysis and was treated with oral vancomycin. This case underscores the importance of considering CDI as a differential diagnosis in cases of ileus, abdominal pain, and constipation, especially in patients with notable risk factors for CDI. It highlights that the presence of diarrhea or watery bowel movements is not a necessary symptom for CDI testing.

Cerebral Salt Wasting Syndrome in the Setting of Hypovolemic Isotonic Hyponatremia: A Case Report

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.

Cerebral Salt Wasting Syndrome Following Right Occipital Craniotomy in a Patient With Metastatic Lung Adenocarcinoma

Cerebral salt wasting syndrome (CSW) is characterized by excessive natriuresis leading to hyponatremia and hypovolemia. It is commonly encountered among patients who have undergone brain trauma or subarachnoid hemorrhage. The occurrence of CSW after neurosurgical procedures has been frequently reported in the pediatric age group; however, it is a rare phenomenon in adults. We describe the case of a 59-year-old female who developed symptoms of polyuria and polydipsia after a right occipital craniotomy.

Changes in Serum Creatinine Levels Can Help Distinguish Hypovolemic from Euvolemic Hyponatremia

Background and Objectives: Differentiating between hypovolemic (HH) and euvolemic hyponatremia (EH) is crucial for correct diagnosis and therapy, but can be a challenge. We aim to ascertain whether changes in serum creatinine (SC) can be helpful in distinguishing HH from EH. Materials and Methods: Retrospective analysis of patients followed in a monographic hyponatremia outpatient clinic of a tertiary hospital during 1 January 2014−30 November 2019. SC changes during HH and EH from eunatremia were studied. The diagnostic accuracy of the SC change from eunatremia to hyponatremia (∆SC) was analyzed. Results: A total of 122 hyponatremic patients, median age 79 years (70−85), 46.7% women. In total, 70/122 patients had EH, 52/122 HH. During hyponatremia, median SC levels increased in the HH group: +0.18 mg/dL [0.09−0.39, p < 0.001], but decreased in the EH group: −0.07 mg/dL (−0.15−0.02, p < 0.001), as compared to SC in eunatremia. HH subjects presented a higher rate of a positive ∆SC than EH (90.4% vs. 25.7%, p < 0.001). EH subjects presented a higher rate of a negative/null ∆SC than HH (74.3% vs. 9.6%, p < 0.001). ROC curve analysis found an AUC of 0.908 (95%CI: 0.853 to 0.962, p < 0.001) for ∆SC%. A ∆SC% ≥ 10% had an OR of 29.0 (95%CI: 10.3 to 81.7, p < 0.001) for HH. A ∆SC% ≤ 3% had an OR of 68.3 (95%CI: 13.0 to 262.2, p < 0.001) for EH. Conclusions: The assessment of SC changes from eunatremia to hyponatremia can be useful in distinguishing between HH and EH.

Prevalence of adrenal insufficiency among patients with euvolemic hyponatremia

BACKGROUND

The diagnosis of syndrome of inappropriate anti-diuresis requires the exclusion of secondary adrenal insufficiency (AI) among patients with euvolemic hyponatremia (EuVHNa). Studies have suggested that about 2.7-3.8% of unselected patients presenting to the emergency room with EuVHNa have undiagnosed AI and it is as high as 15% among patients admitted to specialized units for evaluation of hyponatremia.

OBJECTIVE

To study the prevalence of AI among in-patients with EuVHNa in a general medical ward setting.

METHODS

This was a prospective, single-center observational study conducted among general medical in-patients with EuVHNa, defined as patients with a serum sodium <135 mmol/L, clinical euvolemia and urine spot sodium >30 mmol/L. Additionally, patients with recent vomiting, current renal failure, diuretic use and those with uncontrolled hyperglycemia were excluded. Adrenal functions were assessed by a modified adrenocorticotropic hormone (ACTH) stimulation test called the Acton Prolongatum™ stimulation test (APST). A cut-off cortisol value of <18 mg/dL after 60 min of ACTH injection was used to diagnose AI.

RESULTS

One hundred forty-one patients were included and underwent an APST. APST suggested 20/141 (14.2%) had undiagnosed AI. The commonest cause of AI (9/20) was secondary AI because of the use of steroids including inhaled steroids and indigenous medicines contaminated with steroids. In 5 (3.5%) patients hypopituitarism was newly diagnosed. Despite primary AI (PAI) not commonly presenting as EuVHNa, 2/20 patients had PAI.

CONCLUSIONS

AI is much commoner in our country, among in-patients with EuVHNa primarily driven by exogenous steroid use and undiagnosed hypopituitarism.

Urea in cancer patients with chronic SIAD-induced hyponatremia: Old drug, new evidence

BACKGROUND

Syndrome of inappropriate antidiuresis (SIAD) is the main cause of hyponatremia in cancer patients. International guidelines indicate urea as an interesting option for chronic SIAD. Nevertheless, strong data to support its use are lacking, and its role in oncologic patients has not been described so far.

MATERIAL AND METHODS

We retrospectively analysed 36 cancer patients affected by moderate or profound SIAD-induced chronic hyponatremia, who started oral urea (initial daily dose 15 g or 30 g) without fluid restriction between July 2013 and July 2018. We analysed mean serum sodium (sNa) increase after 24 hours and percentages of patients who reached eunatremia within 14, 30 and 60 days of treatment, stratifying according to the degree of hyponatremia at diagnosis. Clinical evaluation and biochemical assessment were periodically performed.

RESULTS

Mean sNa was 123 [±4] mmol/L at baseline; after 24 hours of treatment, a mean increase of 5 [±3] mmol/L was observed. Eunatremia was reached by 55.6%, 86.1% and 91.7% patients within 14, 30 and 60 days of treatment, respectively. Trends in sNa normalization were similar in patients with moderate and profound hyponatremia at diagnosis. Rapid sNa overcorrection was avoided in all cases. Urea  was interrupted within  the first  2 months  of treatment in 10 patients, in half cases for rapid neoplastic progression and in the remaining patients for the drug taste.

CONCLUSIONS

In our study, urea was effective in correcting chronic hyponatremia among cancer patients with SIAD. Almost all patients reached eunatremia within the first month of therapy, and urea was globally well tolerated.