Abstract | November 6, 2020

Unusual Presentation of Hyponatremia: Is it Water, is it medications, is it both or more

Presenting Author: Mohammed Afraz Pasha, MD, Internal Medicine Resident PGY1, Department of Medicine, North Alabama Medical Center, Florence, Alabama

Co-Authors: Sumit Goyat, MD, Internal Medicine Resident PGY1, North Alabama Medical Center, Florence, Alabama; Sangeetha Isaac, MD, Internal Medicine Resident PGY1, North Alabama Medical Center, Florence, Alabama; Khushdeep Chahal, MD, Program Director, Internal Medicine Residency, North Alabama Medical Center, Florence, Alabama

Learning Objectives

  1. Identify that Hyponatremia though is a common occurrence in elderly, it is important to consider the diagnosis and recognize its neurological manifestations in younger patients.
  2. Implement an in-depth evaluation to diagnose a multifactorial etiology of hyponatremia where the routine algorithmic evaluation of hyponatremia utilizing the volume status and urine osmolality to ascertain one particular etiology might not be appropriate.
  3. Recognize that goal of treatment with Hypertonic saline is the resolution of acute neurological manifestations than a normalization of sodium levels.

Introduction: Case reports on multifactorial causes and atypical presentations of hyponatremia are infrequent. We present a case of multifactorial hyponatremia in a middle aged gentleman presenting with neurological deficits.

Case Presentation:A 55 year old Caucasian man with history of alcohol abuse, Hypertension and Type 2 Diabetes Mellitus presented with one day history of multiple falls, altered mentation, slurred speech and unilateral weakness. Patient drinks 4-6 beers/day and has recently been consuming around 2 gallons of water/day. Home medications were Hydrochlorthiazide, Lisinopril, Nifedipine, Dapagliflozin and Venlafaxine. Patient was afebrile, pulse 95/min, blood pressure 112/54 mmHg, respiratory rate 22/min and O2 saturation 97% on room air. On examination patient was euvolemic, encephalopathic with slurred incoherent speech. Rest of the exam was benign.

Labs were significant for Sodium(Na) 108 (UrineNa13), chloride 69, glucose 127, Osmolality 218 (Urine Osmolality 374), Cortisol 19, Thyroid Stimulating Hormone 1.3, Creatinine 1.2 (UrineCr 65.8), Blood urea nitrogen 27, Serum alcohol <10. Computer tomography Angiogram Head and neck and Electro-encephalogram(EEG) were unrevealing.

Diagnosis: Differentials for his neurological manifestations included Cerebrovascular-accident (CVA), seizure, Hyponatremia, infectious/metabolic encephalopathy and alcohol withdrawal.

CVA was ruled out, EEG for epileptiform discharges and infectious workup were negative. Signs and sympathetic symptoms of alcohol withdrawal were absent. Uremia, Hyperammonemia or carbon-dioxide narcosis were ruled out. Hyponatremia workup revealed a conflicting picture with low Urine Na suggestive of polydypsia or Thiazide induced Hyponatremia but the High Urine Osmolality suggestive of Syndrome of Inappropriate ADH (SIADH) (table 1). This patient had multiple contributory factors for hyponatremia including medications Venlafaxine (SNRI) and thiazide diuretics, poor nutrition and polydipsia.

Management: Venlafaxine and thiazide were discontinued. Hypertonic (3%) Saline was started until serum Na reached 121mmol/L which improved the confusion and focal neurological deficits. Mental status returned to baseline by day 4. The table shows trend in Sodium levels (fig.1).

Table 1 and Figure 1

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